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Cbe Littarp
of t^e
Dtt)t0fon of ^ealti) affairs
OnH)et0itp of l^ottfj Carolina
This Book Must Not Be Taken
from the Division of Health
Affairs Buildings.
This JOURNAL may be kept out TWO DAYS,
and is subject to a fine of FIVE CENTS a day
thereafter. It is DUE on the DAY indicated
below:
no "^
I TKis Bulletin will be sehifrgeio dnijchizerv of iKe Skit^e upon requesi I
Published monthly at the o6fice of the Secretary of the Board, Raleigh, N. C.
Entered as second-class matter at PostofBce at Raleigh, N. C. under Act of August 24, 1912
{
Vol. 71 ^- JANUARY, 1956 No. 1
CLEVELAND COUNTY HEALTH CENTER, SHELBY, NORTH CAROLINA
THE NORTH CAROLINA STATE BOARD OF HEALTH
RADIO BROADCASTS
Station WPTF, Raleigh, North Carolina—Saturdays 1:20 p.m.
Station WWNC, Asheville, North Carolina-Saturdays-9:15 a.m.
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Hubert B. Haywood, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
Ben J. Lawrence, M.D Raleigh
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta HUlsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, D.D.S., Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M. Jarrett, B.S., Director Sanitary Engineering Division
Fred T, Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departments or on
written request.
CONTENTS Page
Public Health And The Doctor In Civil Defense 2
The Public Health Nurse's Contribution To
The Mental Health Of A Community 6
PUBLIC HEALTH AND THE DOCTOR IN
CIVIL DEFENSE
By C. B. KENDALL, M.D.,
State Board of Health, Raleigh, N. C.
If we have not already done so, it is warfare. He possesses a fleet of over
absolutely essential that we now accept 1,000 bombers capable of delivering
the premise that civil defense—defense CBR agents to any city in this country
against chemical, bacteriological and and returning to base, non-stop. His
radiological agents and the mainten- philosophy of offensive warfare is
ance of a constant state of prepared- definitely based on the devastating
ness against such agents—is a way of sneak attack with thermonuclear wea-life
and a way of life that we must pons. He is capable of doing just that
observe so long as there is necessity if and when the occasion demands and
for any element of national defense, presents. His hand may be restrained
Our principal potential enemy has the by the knowledge that retaliation
knowhow and material for this type of would be immediately forthcoming—but
January, 1956 The Health Bulletin
he need not fear or prepare for such
devastating damage as we must expect
because of the wide and secret dis-persal
of his heavy industry and vital
facilities. We hope that there is a
tender heart behind recent pacific
gestures. We have reason from past
experience to believe otherwise. The old
adage advises us to beware the Greek
bearing gifts. On the day of Pearl
Harbor there were in Washington two
upper-crust Japanese diplomats bearing
olive branches. The day before the
Berlin blockade the city was visited by
sweet- talking emissaries of the Soviet.
Incidents of the dove of peace in one
hand and the spike-studded mace in
the other are evident from day to day.
In 1931 Manuilsky of the Lenin School
of Political Warfare explicitly an-nounced
the poUcy of subversive in-filtration,
lulling the bourgeois into a
sense of security with concessions and
peaceful gestures, and annihUatuig him
when properly softened—this entire
process requiring perhaps 20 to 30
years. There has been no indication of
a change in over-all policy—and the
time may be nearer than we think.
Kaganovich has recently predicted
worldwide victory for Communism in
this century. The recent Geneva con-ference,
of which we expected much,
has, with great travail, spawned a dead
herring.
No setup of civil defense can prevent
the blow from falling. It can, however,
definitely soften it and, if at all effec-tive,
prevent ultimate total paralysis
or complete annihilation. It can help
the survivor to survive—and that, in
brief, is the function. To be able to do
this requires planning, research, organi-zation,
training, the consecrated efforts
of many and the genuine interest and
cooperation of all. This is everybody's
business. The task is tremendous—but
it can be accomplished. The problems
are knotty—but they can be solved.
Preparation and prevention are expen-sive,
and substantial support is requir-ed.
When it is not forthcoming, bricks
must be made without straw—and Mr.
John Q. Publi9«hgs>rfretue|itly demon-strated
that, with leadership and guid-ance,
he can do just that.
It was my good fortune to be able to
attend a two-day seminar put on in
March by the U. S. Public Health Ser-vice
on the fimctions of public health
in civil defense. This was attended by
J. M. Jarrett, our engineer, Dr. Ben
Drake, Mrs. Kneedler, Steve Marsh and
Dr. George Watson, of Durham. We
came away with the feeling expressed
by Mr. Jarrett that, while every detail
had not been covered, we had received
a bad scare, and he has done some-thing
about it in carrying the word to
his sanitarians by means of his district
conferences. We did not find the cover-age
in the program as bad as did a
recent participant in a civil defense
conference in South Carolina, who said
at the halfway mark that the program
was like a hoop skirt, covering every-thing
but touching no important point.
To public health has been definitely
delegated the maintenance of general
and environmental sanitation and dis-ease
prevention and defense against
CBR. The United States Public Health
Service acts as over-aU advisor and
assistant in planning, research, train-ing
and detection and is prepared to
give technical guidance in the prepara-tion
of shelters, protection of utilities
and restoration of facilities. To the
states is delegated the responsibility
for actually setting up proper plans
and organization and for carrying out
training. They are advised and aided
by the Regional set-up (for this
Region, in Thomasville, Georgia). The
lowest echelon is the local organization
and this is of course the most im-portant.
Since the development of the H-bomb
and as a result of studies of its
effects, attention has been sharply
drawn to the necessity for planning for
mass evacuation of whole commimities.
The radioactive fall-out from a modern
thermonuclear device released in Wash-ington
can affect a downwind area 200
miles long and 40 mUes wide. Unpro-tected
survivors of the blast in Wash-ington
would be generally subjected to
The Health Bulletin January, 1956
a lethal dose of radioactive substance,
which would be capable of causing the
death of fifty per cent of the inhabi-tants
of the Philadelphia-Trenton area
if unprotected and ten per cent of
those in New York City.
If warning is suflficient (and we hope
for an hour) many inhabitants can be
evacuated from a potential target area.
Such evacuation becomes easier from
an area in the path of fall-out, and,
with proper information, there will be
more time.
It requires little thought and imagi-nation,
however, to appreciate the
stupendous problem presented by a
rapid mass evacuation. To be prepared
for such, it is absolutely essential that
there be planning down to the last de-tail
and organization by precinct, ward,
street, block and family, with every
individual instructed thoroughly in
what to do, where to go and to whom
to look for orders. Every family should
have a least one thoroughly trained
member—and a survival kit. In the
exodus from the community minutely
detailed organization of transportation
and traffic is required. The proper
routes must be selected for the many
columns, and these must be finally
chosen with a knowledge of the direc-tion
of winds and fall-out and of the
width of the fall-out area. A temporary
staging area would probably be neces-sary
to evaluate all elements before the
final receiving area could be selected.
In such a movement public health and
medical personnel would face all the
problems of support in primitive condi-tions,
and a knowledge of elementary
and basic field sanitation and emer-gency
sanitary equipment, as taught
and used in the armed forces, would be
of tremendous value.
Every area and community that can
be possibly used for the reception and
care of evacuees must be thoroughly
studied for resources, those resources
listed and arrangement made for im-provised
and emergency supplementa-tion.
Exposure to radioactive material may
produce a variety of reactions from
mild tissue disturbance, through pre-cancerous
lesion, to tissue destruction
and death. Susceptibility to infection
is increased. Sublethal exposure of
evacuees becomes a public health prob-lem.
There are defensive measures of im-portance
where a blast is delivered
without warning. The survivors must
dig in and seek cover from fall-out.
Preparation for defensive measures
consists of the spreading of informa-tion,
recruitment of personnel and
training. Training in first aid and in
home nursing is important and must
be stressed and carried on with vigor
and wide coverage.
Teachers must be recruited ,from
those with knowledge of medical emer-gencies
and nursing. Instruction in aid
for radiological casualties will be im-proved
by the use of science teachers
and handlers of radioisotopes. Wardens
and sanitary personnel must become
familiar with the use of the Geiger
counter. A detection apparatus the size
of a cigarette package is being worked
out now with changes in the color of
fluid in tubes the diagnostic element.
We hope to have in the not too dis-tant
future a Geiger apparatus to be
placed in the hands of district sani-tarians
for demonstration and instruc-tion
of sanitary personnel in the five
districts. The efficacy of improvised
shelters should be stressed and plans
for them made available. The old vege-table
or root cellar with a three foot
roof of earth is a simple and effective
protection.
Biological warfare can be effective
against crops, domestic animals, hu-mans
and water and food facilities. It
is an agent that could be particularly
devastating against an uprooted and
primitively existing population. An in-vader
might choose to use it as being
less destructive of facilities in an area
that he plans to occupy. Surely some
rather exotic agent would be used, one
that is difficult of destruction, easily
grown and distributed and capable of
effect through various body systems.
Anthi-ax has been suggested as meet-
January, 1956 The Health Bulletin
ing most requirements, but such sug-gestion
has not been impressive to us
in this State who are aware of a
surprisingly small outbreak of the
disease among several hundred em-ployees
of a factory who worked for
some time with material and in an
atmosphere heavily laden with the
organism.
The thought of such an agent in
warfare is a peculiarly horrifying one.
If you wish to appreciate what epi-demic
disease can do in a commmiity
ignorant of the cause, unprepared and
thoroughly frightened and demoralized
reread the description of bubonic plague
in London appearing in the popular
novel "Forever Amber".
Essential in defense are facilities for
early recognition of the agent, early
diagnosis of disease and early report-ing.
Research is being carried out on
means for practically automatic detec-tion
of organisms. Local laboratories
must keep abreast of all advances and
there must be a network of sampling
facilities. All must bear in mind that
they can receive aid through State and
Federal agencies in event of necessity.
Plans must include arrangements for
the protection of utilities and other
facilities against overt or covert attack.
Stockpiling of drugs is an element of
all plans, and health departments must
be prepared to carry out emergency
sanitation measures.
Individuals may receive some pro-tection
from masks, clothing, shelters
and evacuation. After an attack comes
diagnosis of the agent, treatment of
casualties, education of the people in
the treatment and use of contaminated
supplies, decontamination with heat,
chemicals and soap and water and
disposal of unsalvagable material. Vac-cine
prophylactics may be indicated,
and the elaboration of polyvalent prod-ucts
is possible.
Most of us are somewhat familiar at
least with the possibilities of chemical
warfare and know that protection has
been devised. Such warfare has been
outlawed by civilization, but you must
note that we have continued to support
a chemical warfare component in the
armed forces.
The U. S. Public Health Service has
provided training facilities in the pub-lic
health aspects of civil defense in
the Advanced Civil Defense Center at
Atlanta and the Sanitary Engineering
Center in Cincinnati. Here courses of
varying lengths are available as are
extension courses, manuals and bro-chure
material. They are well worth
the consideration and patronage of all
of us.
In many endeavors of this life and
age it must be recognized that, if they
are to be carried out enthusiastically
and well, they will find some of their
most enthusiastic sponsors in the
women of the country. The American
Nursing Association takes an active
part in the councils of Federal Civil
Defense, and the North Carolina
Nui-ses' Association has an active civil
defense group headed by Mrs. Mary
Dunn of Watts Hospital. Plans exist
for the utilization of nurse power
through the military, civil defense and
the American Red Cross. A good pre-paration
for civil defense nursing
function for those nurses who can
qualify is a period of service in the
armed forces.
"Nm-sing During Disaster" is a bro-chm-
e that is available and instructive.
The point may be made here that the
term "disaster procedure" may be more
palatable than "civil defense" and cer-tainly
its more general use may pro-duce
more general interest inasmuch
as all the planning, organization and
training advised and carried out by
"civil defense" is intended also for very
practical application in catastrophes
that may be laid upon us other than
by an enemy invader.
The American Hospital Association
has a committee on mass casualty care.
What local organization and planning
has resulted, I do not know. It must
depend upon the alertness and en-thusiasm
of the local hospital adminis-trator
and his staff and upon the vigor
and foresightedness of the local direc-tor
of civil defense. Those administra-
The Health Bulletin January, 1956
tors I have questioned have no definite
plan.
Every hospital should have a written
and detailed plan for the handling of
mass casualties; for bed expansion; for
full use of facilities, key personnel,
volunteers. The plan should be adap-table,
should show specific job assign-ments
and should provide for relays
of work shifts, procurement and stor-ing
of supplies, triage, (sorting) with
admission and registration set up, and
evacuation. A blood bank program
should be prepared, and all personnel
should be trained for smooth-running
team work. Triage is extremely im-portant
and should be the function of
the most experienced staff surgeon,
who is prepared to set aside the case
with over half his body burned, who
will die anyway, and the patient with
one-tenth of his body surface involved,
who will get well anyway, and place for
definitive treatment those between
these extremes who can be saved by
treatment.
Every hospital should "mother" an
improvised emergency hospital set up,
manned by young people. It is, per-haps,
around the hospital with a de-tailed
written plan kept up to date that
organization of complete medical ser-vice
for disaster with utilization of all
professional disciplines may be best
effected.
We must depend upon local health
ofl&cers and their staffs to carry the
torch in preparedness for CBR De-fense.
Such preparedness is essentially
preventive medicine. All must discipline
themselves to maintain an interest in
preparedness for a situation that may
never come about. Public health per-sonnel
are accustomed to such disci-pline.
THE PUBLIC HEALTH NURSE'S CONTRIBUTION
TO THE MENTAL HEALTH OF A COMMUNITY
By RUTH A. GWYN,
Public Health Nurse, Forsyth County Health Dept.
Winston-Salem, N. C.
I would like to describe to you how
a public health nurse in our depart-ment
worked with a family which I
shall call the Blake family. The six-year-
old son, Jackie, was progressing
very slowly in school, and it was decid-ed
that a psychological test should be
done on him. The public health nurse
was requested to obtain the medical
and social history. The mother con-sented
and was cooperative but couldn't
come to the school for the conference.
She requested that the nurse inform
her of the results of this test, which
revealed that Jackie's I.Q. was quite
low and that he probably would reach
the limit of his learning capacity
around the 5th grade. The psychologist
advised the nurse to work with the
mother to help her xmderstand and
adjust to Jackie's limitations. Through
repeated visits the nurse was able to
guide her into giving him more under-standing
and into helping him more
with home work and also coimsel her
to lessen her pressure on him. The
school authorities later decided to re-tain
Jackie in the first grade. This was
extremely upsetting to him. The medi-cal
history had revealed that Jackie
had occasional epileptic seizui'es. These
became more frequent. The nurse ad-vised
Mrs. Blake to consult the child's
physician and the school principal. The
decision was then made to socially pro-mote
Jackie. His seizures immediately
became less frequent, his crying spells
ceased and his behavior became more
normal. This mother's response to the
nurse's guidance has become increas-ingly
rewarding. The nurse's confer-ences
with Jackie's teachers have help-
January, 1956 The Health Bulletin
ed ease tension between the home and
school. Mrs. Blake has a younger child
who appears to be even more retarded
mentally than Jackie. She has been
able to accept this child more easily
and with greater determination and
faith in her ability to help him. Her
keen interest in the nurse's visits, her
pride in reporting signs of progress and
her patience and faith have been most
gratifying.
Mrs. Blake has demonstrated no
attitude of rejection toward the nurse,
as was the case at first toward Jackie's
teacher. The nurse doubted that she
would be justified in spending extra
time and effort with this family, but
this experience has convinced her that
her time was—and still is—being well
spent in a supportive role with the
Blake family.
This example serves to show the kind
of contribution the public health nurse
with no specialized training may make
to a family.
The supportive service of the public
health nurse to the families of mental-ly
ill patients, as well as to the patients,
is obviously becoming more necessary.
Increasing emphasis is being focused on
this phase of work in the generalized
program of public health nursing. We
have been—and are—doing mental
health nursing every day, but we
probably have not recognized it as
such.
Public health ntirses have perhaps
been reluctant to accept this role be-cause
of their feelings of inadequacy
and lack of preparation in this area.
This, nevertheless, should not block
them in their efforts to see the patient's
and his family's mental health needs
and to broaden their services to include
more mental health teaching. Because
of her skill in human relations, her
training and experience with other ill-nesses,
it is logical to expect her to
offer some help to families in which
there is mental illness.
It is not expected of public health
nurses that they give psychiatric
therapy to the patient or the family,
but there is some help which all nurses
who work in a generalized program
should be able to render. It is a
recognized fact that a public health
niu-se who has had specialized training
in mental health is qualified to give the
greatest help, but one writer has ex-pressed
the feeling that the niu-se with-out
the formal training may very
effectively relate herself to the patient
and family in a less technical way,
since she may, more or less, be con-sidered
a big sister to some families.
Should she not trust her own informa-tion
and impressions as she does in her
other activities, such as helping a
tuberculosis patient accept his diagnos-is?
Isn't she quick to sense a mother's
rejection of her pregnancy? Does she
not then try to direct her efforts to
help her accept the role of mother-hood—
realizing the effect her attitude
has on the expected baby and the
whole family? The nurse recognizes the
importance of the mother's mental
health as well as the necessity for
getting good physical care.
Probably one of the most important
qualifications a nurse could have is her
sincere interest in the promotion of
good mental health and her desire to
make her services more meaningful in
this area. Her ability to be a sympathe-tic
listener and inject her feelings of
real warmth into a situation is of prime
importance.
The nurse's own feelings may deter-mine
to a great degree the quality of
help she is able to give mentally ill
patients, as well as all other patients.
She probably meets more negative
attitudes regarding her help, but pat-ience
and understanding need to be
employed. She must make her own
decisions as to the techniques she will
try in each individual setting. She
usually can soon recognize the capacity
and readiness of the family and patient
to use her help. The niu"se is accustom-ed
to working with normal, reasonable
people. She does not always get com-plete
cooperation in making other types
of visits. Several visits may be required
in order to accomplish her purpose.
Then, because of the very nature of
8 The Health Bulletin January, 1956
mental illness, should she be discourag-ed
if she meets with even less or
slower response from mental patients
and their families?
More and more educational material
Is being made available to the nurse
through nm-sing and medical journals
to increase her interest and knowledge
in this field. One can hardly pick up a
magazine today which does not con-tain
an article relating to mental
health. More booklets are available in
our health departments which ofifer
help.
In our local department the in-ser-vice
educational meetings, led by Dr.
Roger Howell, of the University of
North Carolina, and Miss Dorothy
Boone, of the State Board of Health,
have been most helpful. They have
greatly stimulated our thinking and in-creased
our imderstanding of mental
and emotional problems.
Also, Dr. Lloyd Thompson and mem-bers
of his staff at Graylyn Hospital
have shared with us their knowledge
and experience, which have been help-ful.
These soiu-ces of help have served to
guide us in seeing how we may be-come
more aware of our need to recog-nize
problems and to make better use
of our resoiu-ces to help meet the needs
of our families.
Some of the resources which we have
used and are cm-rently using are: (1)
the adult mental health clinics, (2) the
child guidance clinic, (3) the special
classes for exceptional children spon-sored
by the city and community school
systems, and (4) the psychological
teams from Graylyn Hospital, who work
in our schools, as was illustrated in the
Blake family situation.
The value of helping families and
patients to seek spiritual guidance can-not
be overlooked. Such help can be
very meaningful to some people espec-ially
to elderly ones and to some who
find experiences such as adjustment to
the death of a loved one very difficult.
The Department of Pastoral Care of
a local hospital is a source of help in
some cases. In others, the family minis-ter
or priest may give such service. The
nm-se may need only to guide the
family in identifying such a need.
The nm'se can help share the respon-sibility
in the community for promot-ing
a mental health education program
by (1) helping minimize the stigma
attached to mental illness, (2) helping
people to recognize early symptoms of
mental illness and the value of early
diagnosis and treatment, (3) helping
our communities to understand better
how to accept the patient back into the
community when hospital treatment
has been used, (4) making available
information regarding educational ma-terials,
such as suitable films and book-lets
and the media of radio and tele-vision,
(5) making known community
agencies which offer help and, (6)
pointing out factors which contribute
to poor mental health.
The factors involved in good physical
health are known by a reasonably large
number of people, but far fewer have
a reasonable knowledge of good mental
health.
The nurse may have the opportunity
to suggest resoiu-ce people in leading
discussions in P. T. A. and civic group
meetings.
Helping in the rehabilitation of the
patient may again become the nxirse's
function. Finding diversions to boost
the interest of the patient, such as
games and crafts, is useful. Constant
encouragement and reassurance of the
patient and his family are needed to
help him adjust to the family and
comjnunity.
To me, the greatest challenge in
public health nursing today is the in-tegration
of all phases of mental health
in our everyday activities.
FEB 16 19S6
OlVlSiON OF
Hfc&LTH l^t^^ '^r^m
MHplOMi
"^ ^^^\ TKis Bulletin -will be scni freey^odnil citizen of iKe 5kt^e upon request I W-Published
monthly at the offlce of the Secietary o£ the Board, Raleigh, N. C
Entered as second-class matter at i>ostofEce at Raleigh, N. C. under Act of August 24, 1912
Vol. 71 FEBRUARY, 1956 No. 2
T
We must not in the Course of
Publick Life expect tmmed-iaU
Approbation and immediate
grateful Acknowledgment ofour
Services.^^But let us persevere
thro' Abuse and even Injury. The
internal Satisfaction of a good
Conscience is always present
and Time will do us Justice
in the Minds of the People
»
even of those at present the
most prejudiced against us«
^^^^^tp ljy2
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Hubert B. Haywood, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
Ben J. Lawrence, M.D Raleigh
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta Hillsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, D.D.S., Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M Jarrett, B.S., Director Sanitary Engineering Division
Fred T. Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departmenta or on
written request.
CONTENTS Page
The Second Year Of American College Of Preventive Medicine 2
Notes and Comment 5
THE SECOND YEAR OF
AMERICAN COLLEGE OF PREVENTIVE MEDICINE
By J. W. R. NORTON, M.D., M.P.H., F.A.C.P.M.*
State Health Officer, Raleigh, N. C.
George Dame, our first President, got lines of our constitution and by-laws.
our infant organization off to a run- Except for basic principles as points of
ning start with his unflagging energy reference we should be a changing,
and pioneering zeal. We shall always moving, dynamic body. As we become
owe much to him for our propitious older we must exert increasingly vigor-beginnings:
for his calling the organi- ous force against becoming a static or
zation meeting in St. Petersburg and reactionary group.
presiding also at the second meeting in ^^ ^^.^ ^^^^^^ grateful to the Ameri-
Chapel Hill, leading in outlmmg our
^^^ ^^^.^^^ Association and to the
objectives and shapmg the broad out- . . _ ,-„ .. ,,j-- •^ American Board of Preventive Medicme
•Presidential address before opening ses- for making our existence possible. For
m^sSrrNoVember^ef 1955^'
^''"'^' ^'^^' their continuing helpful assistance and
February, 1956 The Health Bulletin
for that of the American Public Health
Association, we shall ever be apprecia-tive.
We shall make fewer mistakes of
omission and commission if we proceed
"not in entire forgetfulness" of our
humble beginnings and of those sup-porting
our first awkward steps. We
can and must earn the respect of the
older specialist board groups. Those
here tonight, and those who could not
attend, have a strategic opportunity to
shape and to steer our destiny now
while we are young and more respon-sive
to such individual efforts. We have
the responsibility to see constructive
guidance provided toward growth in
strength and influence—"in wisdom, in
stature and in favor." We can begin by
simply promoting growth in numbers
through encouraging qualified persons
to take the Board examination, join
our College and work with us in wield-ing
increasingly constructive support
for preventive medicine. The deadline
for becoming charter members con-tinues
through the present calendar
year.
We must grow in quality as well as
size. Sound work deserves accurate and
prompt recording and documentation.
Reporting and discussion among our
able group will identify, clarify and
define our primary problems and op-portunities.
Stimulation toward logical
next steps in careful evaluation and
vigorous progress should follow. Our
group is in a peculiarly good position
to cut down on the lag between acquisi-tion
and the general utilization of pre-ventive
medicine information. Our per-sonal
as well as our professional con-duct
can build credit and good will. As
collectively and individually we use our
almost limitless opportunities for pro-motion
of preventive medicine the
initials of our College will become a
trademark of prestige and respect. Let
us not, however, become impatient for
recognition nor weary in well-doing.
Modesty, patience, dependability are
becoming to any age and especially to
youth. While recognizing that haste
causes grave mistakes we must retain
our enthusiasm to move forward.
Our purposes, ideals and services will
grow. Think of the simple beginnings
of any of our great and good organiza-tions.
In many respects their growth
has been comparable to the lives of our
most useful men and women. We should
not demand nor even expect "the dis-tant
scene", but with each well-placed
forward step the mists will clear and
our horizons should enlarge.
Each of us has, or has had, the
question: "With so many professional
organizations already, is there need for
the American College of Preventive
Medicine?" Our answers will vary.
What can this body accomplish that
could not be as well, or better, done by
one longer in operation? I shall men-tion
a few and invite each of you to jot
down and hand or mail to me your
own thoughts, and I shall see that they
are given consideration in planning for
the future.
1. Neither preventive medicine nor
our component parts—public health,
aviation medicine and occupational
medicine—has organized and concerted
promotion and support. We have power-ful
(and sometimes misguided) efforts
for categorical entities, such as poliom-yelitis,
cancer, tuberculosis or venereal
disease. There is glamor and emotional
appeal in these narrow fields—in treat-ment,
in the tangible brick and mortar
of buildings, in even partial salvage of
those crippled by injury or disease and
hence in need of definitive treatment
or rehabilitation services. Our group
should believe more strongly than any
other in that ounce of prevention and
its fundamental economy. Individually
and collectively, we should have a con-vincing
message.
2. There are increasing numbers of
medical graduates in research, teach-ing,
group practice and in civilian and
armed forces government service. A few
of these in their confusion and lack of
appreciation of the best in our tradi-tional
concepts tend to infringe upon
the field of private practice. The great
majority of physicians are in individual
fee-for-service practice, and a few of
these are becoming increasingly fear-ful
and impatient with one and all not
in their particular category. Our na-
The Health Bulletin February, 1956
tional good fortune in health and medi-cal
care is not due entirely to any
single group (as some claim) but to
united health and medical efforts and
owe generally high living standard. If
our new organization can work effec-tually
toward preserving individual
freedom and dignity by reorientation of
these disrupting elements within the
medical profession itself and thereby
serve to unify and harmonize all medi-cal
forces against ill health with its
physical and mental disablement and
premature death, and not against each
other, we shall have earned our keep.
3. The component gi'oups of the Col-lege
can serve as an aid and stimulus
to each other as we work more closely.
The story we shall hear tomorrow
morning of the Cornell Automobile
Crash Injury Study provides a clear
example of constructive work started
by aviation medicine and followed
through by public health. Both of these
groups have much to learn from occu-pational
medicine. Our College brings
the leading thinkers and workers of the
three component groups together for
catalytic action.
4. The most important single step in
preventive medicine is the development
and strengthening of local health de-partments
to serve all our people—and
I do not mean branches of the state
health departments. We need more
local autonomy and pride, with a de-sire
to support, financially as well as
otherwise, local preventive services.
Small local health departments can be
operated economically only on a
generalized basis. Our categorical
groups do not realize fully that their
specialties can best be promoted
through this locally supported gen-eralized
setup. We have no clear and
influential voice in behalf of this gen-eralized
approach. Oui- College could
have no more vital vision and goal than
sound decentralized local health de-partments,
employing generalized as
well as specialized workers, providing
an outlet for all categorical or specializ-ed
interests and serving the entire
population. The continuing joint re-sponsibility
for our nation's health
—
local, state and federal—must be recog-nized,
and the College should help in
developing backing of ovir appropriat-ing
bodies so that neither of the three
shall shirk its duty to the other two
and to all our people.
5. Our College may well take a lead-ing
part in the orderly shift of em-phasis
from communicable diseases to
degenerative diseases and special prob-lems
of the aging population, mental
disorders, accidents (and we should
have a more fitting name for this
group), stream and air pollution, nutri-tion,
rehabilitation of the handicapped,
etc. We must keep firm control on the
old while taking in hand the new. Our
knowledge of viruses and mental dis-orders
falls about where we stood in
relation to bacteria a half century or
more ago. Present and rapidly accumu-lating
knowledge and experience make
progress at a livelier pace possible, and
the College can assure its continuing
realization.
The College of Preventive Medicine
is made up of the group best fitted to
point the way and clear the path in the
five areas to which I have so briefiy
referred. You will each think of others
(and so have I, but I picked just these
to mention). Anyway, we have plenty
to challenge our swaddling infant, and
after we learn to crawl and walk we
can move on to run and jump—and
then to really serious and mature
thinking and work.
Finally, a word on our immediate
problems. Our business sessions tonight
and tomorrow enable us to develop our
organizational pattern still further and
better through improvements in our
Constitution and By-Laws. I recom-mend
official incorporation and the
combining of the ofiBces of Secretary
and Treasurer, and we should allocate
a reasonable fund for ofl&ce expenses.
We should decentralize as much as
possible to place the main responsibil-ity
with the State Academies—and in
some states possibly still further to
local units. Our oflBcers should always
be active exponents and supporters of
preventive medicine and not just figure-heads.
Even tho now we see thru the
veil darkly our pioneering spirits re-spond
eagerly as the horizon beckons.
February, 1956 The Health Bulletin
NOTES AND COMMENT
By THE EDITOR
NORTH CAROLINA HOSPITAL
FOOD SERVICE INSTITUTE
The fourth annual Hospital Food
Service Institute will be held at North
Carolina State College, Raleigh, June
13, 14, 15, 1956. This Institute, which is
sponsored by the North Carolina Hos-pital
Association, Dietetic Association
and State Board of Health, is planned
for food service managers in small hos-pitals
having 20 to 100 beds. Hospital
administrators are also invited to at-tend.
Announcements will be sent to hos-pitals
in the above category in the near
futm"e. Each hospital is ui-ged to send
representatives to the Institute. Regis-tration
will be limited to 55, so anyone
wishing to attend should send in the
pre-registration blanks immediately
upon recipts.
Further information can be secured
from the Nutrition Section, State Board
of Health.
ACCENT ON HEALTH
(Municipal Reference Library NOTES,
Vol. XXXIII, November, 1955, No. 9)
"Public health has to do with per-sons
of every rank, of both sexes, of
every age. It takes cognizance of the
places and houses in which they live; it
follows the child to school, the laborer
and artisan into the field, the mine, the
factory, the workshop; the sick man
into the hospital; the pauper into the
work house; the lunatic to the asylum;
the thief to the prison. It is with the
sailor in his ship, the soldier in his
barrack; and it accompanies the emi-grant
to his new home beyond the seas.
To all of these it makes application of
a knowledge remarkable for its amoimt,
and the great variety of sources whence
it is derived. To physiology and medi-cine
it is indebted for what it knows
of health and disease; it levies large
contributions on chemistry, geology,
and meteorology; it cooperates with the
architect and engineer; its work com-mends
itself to the moralist and di-vine."—
From Public Health, a series of
lectures by Dr. William A. Guy,
London, 1874.
The above quotation was called to
our attention by one of the good doctors
in the Department of Health with the
additional information that Dr. Guy,
who was practising in England a cen-tury
ago, also found time to lecture
and write in the fields of physiology,
legal medicine, hygiene, social science,
medical statistics, chemistry, and mic-roscopy.
It's a very large claim he has
staked out for public health, but he
must have had some foreknowledge
that it would be thoroughly worked. A
pity he couldn't have lived on into this
century
!
DOCTOR PREFERS STEAM KETTLE
TO NEWER HUMIDIFIER
The good old steam kettle works bet-ter
than a mechanical humidifier for
treating a childhood respiratory dis-order,
a Haifa, Israel, physician said
recently.
Dr. Abraham Friedman said that the
steam kettle is better because it can
produce more moisture than a cold-air
mechanical humidifier, the now gen-erally
accepted apparatus. Moist air
helps prevent the blocking of breathing
passages which may occur in an acute
infiammatory disease of the larjmx,
trachea, and bronchi.
He explained that in breathing, the
air enters the respiratory tract at room
temperature and humidity. On its way
down the air absorbs moisture from the
membrane lining the passages. It final-ly
is exhaled at body temperature and
saturated with water. The difference in
temperatures and humidities between
the air inhaled and exhaled results in
a continuous loss of water from the
respiratory tract.
In acute respii'atory disease, the loss
is speeded up and the breathing pas-sages
eventually may be blocked by the
formation of a dry crust on the mem-
6 The Health Bulletin February, 1956
branes. The drier the inhaled air, the
more water it absorbs from the mem-branes,
thus increasing their "drying
out."
To prevent obstruction, the air
breathed in must be as moist as the air
breathed out. This means that the
temperature and humidity of the air
inhaled should be approximately equal
to the temperature and humidity of
the air exhaled.
Since there is a ceiling on the amount
of water air will hold at a specific
temperature, the air temperature must
be raised to increase water content.
The mechanical humidifier may raise
water content, but the low-temperature
air cannot hold as much water as high
temperature air would, he said, adding
that a steam kettle accomplishes both
things.
While recormnending the steam ket-tle
method, Dr. Friedman warned that
necessary precautions must be taken
against the hazards of a bum and the
develoment of a high fever in the child.
Dr. Friedman, of the department of
pediatrics of Ramham Government
Hospital, made his report in the Arch-ives
of Otolaryngology, published by
the American Medical Association.
COMMITTEE OUTLINES PROGRAM
FOR POISON CONTROL
The American Medical Association's
Committee on Toxicology outlined four
methods for combating the perennial
problem of accidental childhood poison-ings.
The methods include education, more
stringent laws, establishment of poison
centers, and greater efforts by local
physicians. They were discussed in a
report prepared for the committee by
Dr. Jay M. Arena, Durham, N. C, and
published in the Journal of the Ameri-can
Medical Association.
Bernard E. Conley, secretary of the
committee, said ". . . the curiosity of
children coupled with the casualness
with which many parents handle and
store drugs and chemicals are predis-posing
factors to most unintentional
poisonings."
The "alarming feature" of the prob-lem
is the regularity with which various
household agents and drugs are swal-lowed
by children, the report said.
Leading causes are drugs, especially
aspirin and barbiturates, petroleum
products, lead, corrosive agents such as
lye, and arsenic.
Of approximately 14,000 accidental
deaths that occur each year among
children from 1 to 14 years, almost
1,500 are reported as being caused by
accidental poisoning, but this figure is
"far from correct" for many cases are
never recorded, the report said.
Cnildhood deaths from poisoning
occur disproportionately often in 12
southern states—Alabama, Arkansas,
Florida, Georgia, Louisiana, Mississippi,
North and South Carolina, Oklahoma,
Tennessee, Texas, and Virginia, the re-port
said.
For the barbiturates and aspirin there
is little regional difference, but for
corrosives and arsenic the rate in these
southern states is six times that for the
rest of the country. The rate for
petroleum products, principally kero-sene,
is four times as high.
"Quite apparent to everyone" is the
need for educating laymen and parents
to the dangers of household agents, but
many physicians also are unaware and
must be educated, the report said.
Manufacturers must be made aware of
the seriousness of the problem and of
their responsibilities. They should con-sider
the use of distinctive safety con-tainers
and better labeling with warn-ing
statements and when necessary
uniformly standarized doses for drugs.
While the present federal laws are
useful as far as they go, they are far
from adequate, the report said. Laws
regulating the sale of household articles
not covered by existing laws must be
considered. Physicians and lay groups
should work for state laws to strength-en
federal ones and to bring about
correction of their special state prob-lems.
The report suggested that the sale
of kerosene be restricted except in a
special type of container, which would
also carry a label warning of its
poisonousness and inflammability.
Poison centers should be set up to
collect and distribute information on
February, 1956 The Health Bulletin
the type, frequency, treatment, and
preventive measures for poisonings.
Another step forward would be a
concentrated effort by every physician
to educate parents to the hazards of
household agents. This could be done
by pointing out corrective measures
while making house calls, distributing
safety literature to mothers, using bul-letin
board displays in the office, en-couraging
community programs to
study the problem, and giving infor-mation
to radio stations, newspapers,
and magazines.
Much can be accomplished by asking
pharmacists to put labels such as "Keep
out of the hands of children" on all
dangerous drugs and agents, the report
said.
Dr. Arena is associate professor of
pediatrics at Duke University and di-rector
of the Poison Control Center of
Durhar?..
"HEAD INJURY EPIDEMIC"
COULD BE PREVENTED
The only cure for the "head injury
epidemic" now sweeping the country is
prevention through safer automobile
construction, a California neurosurgeon
has said.
Head and neck injuries account for
nearly 70 per cent of all auto crash
deaths, Dr. C. Hunter Shelden, Pasa-dena,
said in the Journal of the Ameri-can
Medical Association. In spite of the
"most concerted efforts" of neurosur-geons,
the severe head injury is fatal,
for once the brain is injured beyond a
certain degree, there can be no re-covery,
he said.
Last year there were 5,200,000 report-ed
auto accidents, 1,500,000 resultant
injuries, 100,000 persons totally disabled,
and 38,000 deaths—"rather lethal statis-tics
to refer to a so-called pleasure
car," Dr. Shelden said.
Pressure is developing that will bring
about safety improvements, but so far
there has been "much smoke but no
fire," he said. Changes must be made
at once and not in a piecemeal man-ner.
"Such a delaying action may be a
satisfactory policy in business, but not
in a matter of health and public safety.
Translated into medicine, it would be
comparable to witholding known meth-ods
of lifesaving value," he said.
Engineers have supplied valuable
safety ideas, but they have had only
limited use, because the automobile in-dustry
"apparently is governed entirely
by the cost accounting division," he
said. No new idea can be adopted un-less
it reduces present costs or promises
better sales.
However, safety is the one feature
that the public will accept if given the
opportunity, without the need of
propaganda and expensive advertising,
he said.
Because no company can afford to
imdertake an immediate and complete
safety program. Dr. Selden suggested
that a national group be set up to
regulate and approve automobile safety,
allowing industry to pool safety ideas,
standardize construction methods, and
avoid competition.
Dr. Shelden outlined some suggestions
for improved auto safety, pointing out
that if a medical research group can
devise safer construction methods
engineers could come up with even bet-ter
ones.
Of particular concern in preventing
head and neck injuries is seat con-struction,
which Dr. Shelden called "a
disgrace to the combined engineering
staffs of the automobUe industry."
Seats are designed for comfort and not
for safety. The fixed portion of the
seat is fastened to the frame only by
four small bolts, which allow frequent
seat failures. Seat cushions are not
securely fastened, are easily torn loose
and tossed about in a crash, and can
cause fatal injuries.
Poor seat design accotmts for thous-ands
of "whiplash injuries," which
occur when the car is struck from the
rear. With the impact, the head is
thrown backwards. Since the seat back
is low, the top of the seat serves as a
fulcrum over which the neck is snap-ped.
Whiplash injuries are the most
disabling of all nonfatal auto injuries,
he said.
Dr. Selden suggested that a small
elevated portion of the seat be placed
8 The Health Bulletin February, 1956
directly behind the head—not high
enough to support the head while driv-ing
but high enough to give the head
support if the neck is suddenly extend-ed.
He also said a method that would
rigidly attach both doors to the out-side
edges of the front seat backs is
needed. This would hold the doors
tightly shut and prevent the front seat
backs from flying forward. A better
locking method is necessary to keep
passengers from being thrown from the
car. Between 25 and 35 per cent of all
deaths occur in this manner.
There has been some improvement in
interior projections, but dashboards still
have dangerous knobs and buttons that
can "easily produce" serious depressed
skull fractures in a crash, he said. He
also suggested the addition of a roll
bar to prevent the crushing of the pas-senger
compartment if the car rolls
over.
He said current safety belts with two
straps are inconvenient, because the
free ends when not in use lie across the
seat, fall out the door or on the floor.
In order to fasten the belt, both
hands must be taken from the wheel
and attention turned from the road. A
belt that rolls up when not in use and
can be fastened with one hand would
improve the situation. Until improved
designs are available, the public is not
going to take full advantage of safety
belts, he said.
"Eventually a method must be de-veloped
whereby the passenger is auto-matically
and instantaneously restrain-ed
during a crash," he said.
COMMITTEE TELLS DANGERS
OF INSECTICIDE
The Committee on Pesticides of the
American Medical Association has
warned of the danger of poisoning by
chlordane, an agricultural and house-hold
insecticide.
Deaths following chlordane poisoning
were reported in the Journal of the
A.M.A. as part of a discussion of the
possible hazards of using the insecti-cide.
Poisoning may be caused by repeated
skin contact, breathing of the fumes or
accidentally swallowing the chemical.
Chlordane appears to be absorbed more
rapidly than similar insecticides, the
report said.
Chlordane is effective in controlling
such pests as grasshoppers, ants, flies,
mosquitoes, and roaches. It is avail-able
in oil solutions, emulsion concen-trates,
dusts, paints, and waxes.
The insecticide should not be used on
food crops with exposed edible parts or
on crops fed to animals, because the
chemical can be retained in the food
and in milk, eggs, and meat, the com-mittee
said.
Its use in the home should be limited
to spot treatment around kitchen base-boards,
doors, and windows. Care should
be taken to avoid areas frequently con-tacted
by children. It is not approved
for over- all interior use, because slow
liberation of fumes, especially in closed
heated rooms, is dangerous.
Because chlordane is readily absorb-ed
through the skin, the committee
cautioned against its use in insecticidal
waxes and polishes which touch the
skin.
Symptoms of chlordane poisoning in-clude
irritability, labored breathing,
muscle tremors, convulsions, and deep
depression. Others are nausea, vomit-ing,
diarrhea, abdominal pain, blurred
vision, cough, confusion, and delirium.
The onset of symptoms is influenced
by the means of absorption. Acute signs
usually appear within 45 minutes after
swallowing the poison. Death may
occur within 24 hours and is frequent
between the 48th and 96th hoiu:, the
report said.
The treatment consists of removal of
the poison from the skin or stomach,
followed by a salty purge and adminis-tration
of sedatives. In case of skin
contact, the contaminated area should
be washed immediately with soap and
water. If chlordane is swallowed, wash-ing
of the stomach, followed by ad-ministration
of epsom salts or other
salty cathartics is recommended. Since
milk, oil purgatives, and other fatty or
oily substances speed absorption of the
poison, they should be avoided.
u
WJJ^^'i^^ ^^
F£3 16 1936
DiV5iON OF
jjEALTH^iRS LIBRARY
l(i®lllb®il
I TKisBuUefin. will be sehi hezfo dnij ciiizen of fKe Skite upon request i
Published monthly at the office of the Secretary of the Board, Raleigh, N. C.
Entered as second-class matter at /"ostoffice at Raleigh, N. C. under Act of August 24, 1912
Vol. 71 MARCH, 1956 No. 3
STOKES COUNTY HEALTH CENTER
Danbury, North Carolina
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Ben J. Lawrence, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta Hillsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
Lenox D. Baker, M.D. Durham
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, D.D.S. , Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M. Jarrejt, B.S.. Director Sanitary Engineering Division
Fred T. Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departments or on
written request.
CONTENTS Page
Life and Death In 1955 2
Notes and Comment 5
LIFE AND DEATH IN 1955
BY WILLIAM H. RICHARDSON
State Board of Health
Raleigh, North Carolina
For many years now, the State Board Statistics, as such, mean very little
of Health has maintained an increas- to the average person, but, when prop-ingly
accurate record of births and erly interpreted, they can furnish a
deaths in North Carolina. All births are world of interesting and helpful infor-reportable,
as well as all deaths. There- mation. The mere fact that a given
fore, under the present system, the number of people came into being dur-
State Board of Health is able to collect ing a certain year, or that a certain
and to give out information as to the number died, means very little. There
cause of each death reported. Such rec- is more human interest attached to
ords as those just referred to are known deaths from various causes than to
as vital statistics—the "bookkeeping of births. The method by which people are
life and death." born into the world has never changed.
March, 1956 The Health Bulletin
so far as we know, but the causes of
death have varied through the years.
Some diseases which formerly took a
heavy toll of life each year now are
practically extinct. We shall get to that
later.
The State Board of Health issues a
month-by-month report of births, total
deaths and deaths from selected causes.
Each of these reports is cumulative.
The most interesting, however, is that
which appears when all preliminary
figures for December have been receiv-ed.
This report, which is issued during
the first part of each year for the
previous year, is provisional and is sub-ject
to changes imtil all reports have
been received, compiled, and verified.
Some time ago the Public Health Sta-tistics
Section of the State Health De-partment
issued its provisional figures
for 1955, showing the results of the
"bookkeeping of life and death" in this
State during the past calendar year.
At first glance, this report is just so
many figures. Analyzed, however, it
shows a progressive pictui-e of the
health of our people over a period of
years. Published reports carry a sum-mary
of all births, including and since
1914, and of deaths from selected causes
including and since 1916.
New High Birth Total
Let us now pinpoint the provisional
figures for 1955 and make some inter-esting
comparisons, as we proceed. Last
year North Carolina's total number of
live births reached an all-time high,
nath 116,206 reported up to the time the
provisional figures were compiled. Dur-ing
the previous year, that is 1954, the
total was 115,889. We now have a popu-lation
of more than four and a quarter
million people.
In 1914, when our population was
estimated to be 2,421,191, the nimiber of
live births reported to the State Board
of Health was 71,931. Just what the
actual total was we will, perhaps, never
know. That was the first year for which
figures were published, and the report-ing
system was very inadequate, as
compared to the present time.
As previously stated, we all enter this
world through one door, namely natui-al
birth; but, although the wall of parti-tion
between this life and the next is
death, there are many doors through
which people pass into the Great Be-yond.
Through the miracles of medical
science, many of these doors which
formerly beckoned thousands to pass
thi'ough their portals have been all but
closed, certainly in the United States.
We might take typhoid fever as one ex-ample
of this. The 1955 provisional re-port
does not even mention typhoid
fever, because there was only one death
from that cause in 1955, while in 1916,
702 typhoid and paratjTDhoid deaths
were reported to the North Carolina
State Board of Health. During that
same year, malaria deaths reported
totaled 337, while none occured in our
State last year. Both typhoid and ma-laria
have been practically eliminated
through immunization, sanitation and
drainage; but, if we should lower our
guard, these killers would seize the op-portunity
to strike again.
Before taking up the subject of other
deaths from selected causes, let us
pause for a moment and consider two
comparative totals. In 1914, when our
population was less than two and one
half million, 29,044 deaths from all
causes, were reported to the State
Board of Health. Last year, with a pop-ulation
of more than four and a quarter
million, only 32,469 deaths from all
causes, were reported. To tell the whole
story would require much more time
and space than are available.
Certain Notable Declines
Before pointing up this discussion
with some extremely significant facts,
suppose we review, briefly, the decline
in deaths from certain diseases which
have been brought under control
through the application of the prin-ciples
of preventive medicine.
We shall begin with the cradle and
tell what it furnished the grave. In
1914, when there were only 71,931 live
births reported in North Carolina, there
were 6,497 deaths reported among in-fants
under a year old. Compared with
that, there were only 3,577 such deaths
The Health Bulletin March, 1956
reported last year, when the total num-ber
of live births was 116,206.
Before leaving this field, let us note
one other extremely interesting com-parison.
In 1914, with the number of
live bu'ths previously referred to, ma-ternal
deaths numbered 524, that is.
there were that many deaths resulting
from pregnancy and childbirth. Last
year, when there were more than 116.-
000 live births reported in North Caro-lina,
only 100 mothers laid down their
lives. We shall not go into the causes
for this phenomenal decline, the broad
reason for which has been the more
affective application of the principles
of preventive medicine.
Compulsory Immunization
Nearly two decades ago the legislature
of North Carolina passed a law requir-ing
the immunization of children
against diphtheria during the first year
of life. How has this worked? We still
are thinking in terms of preventive
medicine. In 1916, when our babies and
small children were wide open to at-tack
by this disease, 410 died. In com-parison
with this, there were only four
diphtheria deaths reported in North
Carolina in 1955. During 1939, when the
immunization law v;as passed, there
were 164 deaths among our children,
resulting from diphtheria. The decline
since that date has been steady, with
only one flare-up. That was in 1945.
Despite the fact that this law may not
have been enforced as it should have,
we have seen the results previously re-ferred
to. It would seem therefore, that
enforcement is becoming more uni-versal.
Whooping cough is another childhood
disease which is being brought under
control by preventive medicine. Com-pulsory
immunization against this dis-ease
is required by a law passed in
1945. During that year, there were 97
whooping cough deaths reported in
North Carolina. By 1953 the total had
been reduced to seven, while only ten
whooping cough deaths were reported
in 1954; but, in 1955, for some reason,
there were 32. Whooping cough, as all
of us know, occurs in cycles. Even be-fore
the immunization law was passed,
it had become preventable, and many
parents were resorting to immimization
as a means of protecting their children.
It might be well to state, in this con-nection,
that if whooping cough had not
been known to be preventable, the State
Board of Health would never have
sponsored a law requiring immuniza-tion.
Public health never considers an
experiment. Any preventive agent must
have proved itself before it is either
adopted or advocated by those who are
charged with the mass protection of
our people.
Another disease that has been suc-cessfully
attacked through the use of
new drugs in pneumonia. There was a
time when all a patient and his attend-ing
physician could do was to await
"the crisis" and, when that was suc-cessfully
passed, to administer, perhaps,
some stimulant and pray that the pa-tient
was on the road to recovery.
It is not customary to mention "rem-edies"
in a discussion of this nature,
but we do know that, through the use
of certain drugs which can be prescrib-ed
only by physicians, pneumonia in-fection
often can be cleared up within
a comparatively short time. During
1955 influenza and the various types of
pneumonia resulted in 1,203 deaths in
North Carolina. That was a large num-ber,
to be sure. But what about what
many call "the good old days?" In 1916
there were 2,517 pneumonia deaths re-ported
to the North Carolina State
Board of Health. In 1918, the year of
our biggest flu epidemic, there were
4,210. As late as 1934 pneumonia deaths
totaled 3,173. Since the discovery of cer-tain
antibiotics, deaths have been on
the decline during most years. However,
statistics show that this disease is not
entirely whipped, by a long way.
In 1955 there were only 11 polio
deaths reported in North Carolina,
compared with 23 the previous year.
The largest number ever reported was
143 in 1948, when we had our biggest
epidemic. While polio is a dreadful dis-ease
and its crippling effects are very
distressing, in many instances, it is a
small killer compared with accidents
March, 1956 The Health Bulletin
and some of the others that can be
prevented.
Some Significant Facts
Let us now bring this discussion to a
climax with some statistics that are
more than just so many figures. More
people today are living to a "ripe old
age" than ever before in our history.
A hundred years ago the average span
of life was around 40 years. Today it
has about reached the Biblical standard
of "three score years and ten." There
are more old people among us today
than ever before and more who have
passed the dangers of infancy, child-hood
and middle life. These people are
subject to causes of death which are
not so common among young people.
These are commonly called the degen-erative
diseases. Without undertaking
to explain what is meant by that term,
let us consider a few startling figures.
Early in this discussion it was point-ed
out that the total number of deaths
occurring in North Carolina last year,
from all causes, was 32,469. Of this
number, 11,245 died as the direct result
of heart disease; 4,440 were victims of
apoplexy, and 3,939 died of cancer.
Deaths from each of these diseases
continue to climb with the passing
years and with the increasingly large
number of people who live to reach old
age. These three causes last year ac-counted
for 19,624 deaths, out of a
total of 32,469. None of the three has
yet been classified as preventable. On
the other hand, they present a gigantic
challenge to practitioners of the med-ical
profession, both curative and pre-ventive.
That is why public health con-siders
the degenerative disease in the
category of those human ailments
which must be studied with a view to
bringing them within the range of pre-vention.
Physicians have found that persons
suffering from any of these diseases
need not consider themselves in a
hopeless plight. Those with diseases of
the heart and circulatory system can
be taught ways and means of living
with the conditions luider which they
suffer, if they will consult their family
physicians while there is yet time. Some
cases of cancer can also be cured, if
discovered in time for proper treatment.
And so we bring to a close a discus-sion
of life and death in North Caro-lina
for 1955.
NOTES AND COMMENT
BY THE EDITOR
PARENT-CHILD CONFLICTS
CAUSE BREATH-HOLDING
Frequent severe spells of breath-hold-ing
by a small chUd are a sign of "pro-found
insecurity" often resulting from
conflict with his parents, two pediatri-cians
said recently.
Drs. Alanson Hinman, Winston-
Salem, N. C, and Lloyd B. Dickey, San
Francisco, said in the American Journal
of Diseases of Children, pubUshed by
the American Medical Association, that
breath-holding is an early form of
temper tantrum—a primitive expression
of anger or frustration.
A child may become frustrated be-cause
he is unable to cope with the
world or because he feels insecure with
his parents. In his helplessness, having
no means of adequate expression, he
reacts with rage "so overwhelming"
that he loses control over himself and
goes into a spell, they said.
Treatment must be directed toward
a solution of the family conflict and
helping the parents understand the
emotional basis of the spells, the
physicians said. The older methods-plunging
the child into cold water or
ignoring him during a spell or point-ing
out to him that similar behavior
will be met with "harsh, if not painful,
measures"—certainly should be avoid-ed,
they said.
6 The Health Bulletin March, 1956
The little child's only way of pro-testing
against a frustrating world is
by crying and throwing himself around.
Anything approaching the same kind
of behavior on the part of adults will
aggravate the situation, they said.
"Every effort should be directed to-ward
removing the soiu'ces of conflict,
such as coercion in eating, overly strict
or too early bowel and bladder train-ing,
pressure in the matter of naps and
bedtime, and other premature and ex-cessive
demands on the child," they
said.
The parent should be reassured that
the child can receive no physical or
mental damage from the spells them-selves.
They should be helped to under-stand
the difference between discipline
and pimishment and to establish a
"tolerant and consistent disciplinary
regime," the authors said. In some cases
the parents may need help in adjusting
their own emotional problems.
Spells occur most frequently in the
last half of the first year and during
the second year of life. Tliey usually
are precipitated by injury or frustration
and the resulting anger, the physicians
said.
The sequence of events in a spell is:
crying, a long - sustained expiratory
"cry" without succeeding inhalation of
air, a slight blueness or paleness after
the previous flushing of the face, stif-fening
of the limbs, loss of conscious-ness,
relaxation, inhalation, and recov-erj'.
Some children are weak or ex-hausted
after a spell, but most seem
entirely normal after breathing is re-established,
they said.
Breath-holding spells are sometimes
confused with epileptic seizures and
other lesser-known disorders. Epileptic
attacks and breath-holding speUs can
be distinguished because of the differ-ence
in "crys." Convulsions in breath-holding,
"which are rare anyway," are
mild compared to the "dramatic" ones
of epilepsy, and the epileptic seizures
usually do not follow some specific
event such as a fall or frustration.
They said that if any "real doubt"
exists, a thorough medical study should
be undertaken.
The physicians outlined 11 cases
among children ranging in age from
one year to five years, seven months.
There was only one over two and a
half, and the average age, excluding
the oldest, was approximately one year,
nine months.
The age at onset of the spells ranged
from three to 24 months, the average
being a little over 10 months. The fre-quency
of spells ranged from eight
spells in a year to as many as 10 or
15 a day.
In several cases, strained relation-ships
within the family were obvious.
In four cases, there were conflicts about
feeding, and in three, about toilet
training. In three families there was
frustration from relatives living in the
family, and in two there was marital
friction. In at least two, the parents
seemed to be overly demanding and
strict. There was a family history of
breath-holding spells in four.
In six of the children the spells ceas-ed
in a few months. One was much
better two years later, and one, accord-ing
to the family doctor, became an
epileptic. There was no follow-up on
three of the children.
NEWBORN INFANT DEVELOPS
OWN POLIO IMMUNITY
Infants born while their mothers
have acute polio may be infected with-out
showing outward signs, two Mary-land
physicians have said.
In the Journal of the American Med-ical
Association, they told of a new-born
baby who acquired polio from his
mother before or during birth, develop-ed
his own immunity to the disease,
and never showed signs of infection.
As far as the doctors know, this is
the first reported case of infection
without outward signs in an infant bom
during the mother's acute phase of
polio. Further investigation, though,
may show this sort of infection to be
common, they said.
The infant, born about two weeks
after the mother developed an acute
case of polio, was "normal" and remain-ed
"well" at all times. However, lab-oratory
examination of rectal swabe
March. 1956 The Health Bulletin
showed him to be infected with the
same polio virus as his mother was.
Examination of his blood serum re-vealed
many antibodies (agents de-veloped
by the body to combat foreign
substances such as viruses). At three
months, the infant's antibody level was
approximately the same as his mother's.
He apparently manufactured his own
antibodies, since the cord fluid at birth
contained very few and he was never
breast fed, they said. This indicates
that the mechanism for manufacturing
antibodies was well developed even in
the first months of life, they said.
The infant probably acquired the in-fection
before birth, since the placenta
contained viruses. However, he may
have been contaminated with the
mother's virus during delivery, they
said.
The report was made by Drs. Alexis
Shelokov and Karl Habel from the lab-oratory
of infectious diseases. National
Microbiological Institute, National In-stitutes
of Health, Bethesda, Md.
SORE THROAT TREATMENT
CHANGES OVER YEARS
A man with a sore throat today is
better off than George Washington was
when he had one in 1799.
During his fatal illness, which began
with a sore throat, in December of that
year, Washington was treated with "the
best" eighteenth century methods
—
"bleeding," the application of "blisters"
to the neck, gargles, inhalations, cath-artics,
and immersion of his feet in hot
water. Dr. Noah D. Pabricant, Chicago
otolaryngologist, said.
Now treatment for sore throats in-cludes
antibiotics and sulfonamides for
severe cases and the "time-tried" meth-ods
of complete bed rest, adequate
amoimts of fluids, salicylates for the
control of fever and irrigation of the
throat with warm salt water for mild
cases.
In Washington's day, the diagnostic
method of chest thumping and listen-ing
was unknown and no one thought
to examine his throat. His illness was
diagnosed as "quinsy" (an abcess near
the tonsils) and later as "cyanche trac-healis,"
an indefinite medical term then
in vogue for a severe sore throat that
involved the vocal cords.
Although the exact diagnosis of his
illness is a matter of dispute, it seems
likely that a strain of streptococci or-ganisms
was responsible, Dr. Fabricant
said in Today's Health, published by
the American Medical Association.
In past years complications from
"strep sore throats" were common, but
now antibiotics and sulfonamides are
effective weapons against the terror of
streptococcus infection, he said. "Strep
throats" usually start suddenly, with
chills and high fever. Some patients
develop a skin rash, so sometimes it is
difficult to distinguish this disease from
scarlet fever.
The "common, garden-variety" sore
throat usually results from irritation
or infection of the back wall of the
throat (pharyngitis) or of the tonsils
(tonsillitis), he said.
Acute pharjTigitis is caused by many
different types of microorganisms and
viruses. The symptoms include sensa-tions
of burning and scratchiness, a
constant desire to clear the throat,
painful swallowing, fever, headaches,
loss of appetite and a dry, harsh cough.
In the acute stages, pharyngitis grad-ually
wears itself out, but bed rest, ade-quate
amoimts of fluids and salicylates
are helpful. If the fever is or remains
high, use of antibiotics and sulfona-mides
to prevent complications may be
necessary, he said.
While gargling is popular, there is
considerable doubt as to its value. Dr.
Fabricant said. Experiments have
shown that fluids fail to reach either
the back of the throat or the tonsils,
because the gargling causes the back
of the tongue to meet the soft palate,
closing off the back part of the throat.
However, it is possible to irrigate that
part of the throat with a syringe.
Various studies have shown that ordi-nary
mouth washes "can do no more
than wash," he said. They are in con-tact
with the infected area for too
short a time to kill the bacteria and
viruses.
As in acute pharyngitis, antibiotics
8 The Health Bulletin March, 1956
and sulfonamides have taken the
"sting" out of tonsillitis. Bed rest, fluids,
easily swallowed foods and salicylates
also help give relief.
INFECTIOUS DISEASES STILL
TAKE "IMMENSE TOLL"
"Top priority" in the U.S. health
programs must be given to communi-cable
diseases, because they most fre-quently
attack "the young and vigorous
... on whom the present and future
productive power of the nation de-pends,"
a U.S. Public Health Service
official said recently.
While "major killers of a half cen-tury
ago" largely have been controlled,
other communicable diseases still take
an "immense toll" in death and dis-ability
among citizens of the U.S., Dr.
Theodore J. Bauer, chief of the U.S.
Communicable Disease Center, Atlanta,
Ga., said in the Journal of the Amer-ican
Medical Association.
One of every 10 deaths is caused by
a communicable disease. The situation
is "far more serious" in the age group
under 35 years, where the ratio is 1 to
4. In the older group it is 1 to 12. In
addition the diseases cause the majority
of absences from school and work. They
also may lead to future disorders of the
heart, liver, kidney, nervous system and
other organs.
Public health workers aim toward the
control of all communicable diseases.
Dr. Bauer said. Control measures for
diseases of today must be developed
and research into diseases of obscure
origin must continue.
If those "spectacular and dreadful"
diseases of the past, such as yellow
fever, typhus and smallpox, are to re-main
in check, constant watchfulness
and effective use of available control
measures are necessary, he said.
"Perhaps of greatest concern at the
moment" are the "ultramicroscopic"
viruses. Dr. Bauer said. They produce
more than 40 known diseases, among
them polio, the common cold, measles
and mumps. The major problems in this
field include finding the means of
transmission, adequate methods of
diagnosing and ways of controlling the
diseases.
A recently developed problem is the
appearance of bacteria which resist the
action of antibiotics. While antibiotics
have been "dramatically effective"
against such bacteria-caused diseases
as tuberculosis and scarlet fever, their
effectiveness is being lessened by the
appearance of the resistant bacteria.
Ways of controlling these bacteria must
be found.
Some of Dr. Bauer's comments in the
Journal on individual diseases follow:
Poliomyelitis—This complex disease
will continue to be an enigma until the
basic factors governing its occurrence
and spread are found. More efficient
laboratory diagnostic tests are needed.
Viral hepatitis—The viral nature of
this increasingly prevalent disease of
the liver was found only recently. No
control measures have been developed.
Insect-carried encephalitis—Man ap-parently
only accidentally acquires vir-uses
as they go through a complicated
life cycle among other animals. In ad-dition
to the native encephalitis types,
others exist in various parts of the
world. It is not known what natural
forces may introduce these foreign vir-uses
among American insects and ani-mals
or what factors lead to their in-fection
of man.
Psittacosis— Control of this pneu-monia-
like disease, which is spread by
parakeets and some domestic fowl, re-quires
cooperation of owners, producers
and distributors in treating or destroy-ing
diseased birds. No immunizing
agents are yet available for either man
or birds.
Rabies—The virus recently was found
in insect-eating bats, which suggests
that more animals carry the disease
than formerly was thought. The dis-covery
points to the necessity of deter-mining
all animal species that can
transmit the disease to man and do-mestic
animals.
Smallpox—The last outbreak of 11
confirmed cases in New York in 1947
showed that "universal vaccination may
be an accepted principle, but ... is
not universal practice."
ni
FEB 16 1003
DIViSiON OF
y^—~^^\ TKis Bulletin will be seni ifee^ dnij cilizen of tt\e Sktj-e upon request I
Published monthly at the ofBot of the Secretary of the Board, Raleigh, N. C.
Entered as second-class matter at PystofBce at Raleigh, N. C. under Act of August 24, 1912
Vol. 71 APRIL, 1956 No. 4
Av'-^ccow v44fcS:^v
COLUMBUS COUNTY HEALTH CENTER, WHITEVILLE, NORTH CAROLINA
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Ben J. LawTence, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta Hillsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
Lenox D. Baker, M.D. Durham
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, DJ).S., Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M. Jarreit, B.S., Director Sanitary Engineering Division
Fred T. Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departments or on
written request.
CONTENTS Page
Mental Health Needs and Resources In North Carolina 2
Notes and Comment 10
MENTAL HEALTH NEEDS AND RESOURCES
IN NORTH CAROLINA^
Preliminary Report to the North Carolina Academy of Preventive
Medicine of Committee Number One for the Study of Mental Health
BY FRED G. PEGG, M.D.*
Winston-Salem, N. C.
At a meeting of the Academy of Pre- continuous; and that long range ob-ventive
Medicine at Chapel Hill, Janu- jectives should be set up, with sugges-ary
17, 1955, certain projects that might tions as to how to attain them,
enhance the prestige of the Academy Our committee was assigned "To con-and
serve to advance health were con-sidered.
Among them was the study of 'Health Officer of Forsyth County and
Tmve,QnTitfar.li ih,e^a.,l!t*!h,, a„njd it. wo commit-tAees chauman of Committee One. Other com- mittee members are: Drs. B. M. Drake and
were appointed to carry out this study ^- T. Foard, state Board of Health, Ra-
Tm^eP Pcnonncspenncsiuisc ooff +tVh.eQ AA,c>oa,d^«ervm,,yr ^w^a.s^ leigh; and Dr. J. J. Wright. University of North Carolina School Sf Public Health,
that all phases of mental health should Chapel Hill,
be considered: that the study should be ^5"o?£"^?rolinrM^JiTclTJournal
April, 1956 The Health Bulletin Page 3
sider methods useful in determining
the needs of the community in refer-ence
to services for the prevention or
alleviation of mental diseases, includ-ing
techniques and indices which might
be useful." It soon became apparent
that it would be difBcult to limit our
studies to the area specifically assign-ed.
This matter was discussed with the
chairman of the other committee,
which had been assigned to consider
a mental health program for a com-munity
which did not necessarily re-quire
a preliminary survey—for ex-ample,
what clinics might be estab-lished,
what education might be used,
what services might be rendered, and
how mental hygiene can be incorporat-ed
into public health services. It was
decided to include other phases of
mental health in our survey, and, in
order to prevent duplication, to com-bine
the reports prior to final presenta-tion
to the Academy.
General Survey of Mental
Health Problems
The first step in this study was to
make a general survey of the mental
health problems and needs of the com-munity.
It was intended to get as much
factual information as possible and, at
the same time, to determine the think-ing
and reaction of the public to mental
health generally. For example, what
community mental health problems are
considered most important, how can
these problems best be met, what addi-tional
facilities are needed, and so
forth. We discussed mental health with
members of the medical profession,
welfare departments, schools, juvenile
courts, ministers, personnel directors of
industries, social workers, psychiatrists,
and others. All persons interviewed ex-pressed
great interest and seemed
anxious to cooperate; however, the
majority saw the problem from a limit-ed
point of view rather than as an
over-all need. This attitude was to be
expected, since each person was in-terested
primarily in mental health as
it affected his work. General informa-tion
and attitudes in the survey were
easy to obtain. On the other hand,
specific and detailed data were, in most
cases, non-existent.
When we began to compile the re-sults
of our studies, we were struck by
the fact that many different people
and groups were dealing with different
phases of the problem. Since we were
trying to conduct our study from the
community point of view, we decided
that it would be worth while to classify
mental health problems as nearly as
possible as they were seen by the
people of the community who deal with
them from day to day.
Mental Health Problems as Seen by
the Community
The psychotic group
The group in which the community
seemed to be most interested was the
psychotic, which includes those indi-viduals
who have been treated and re-turned
to the commvmity, those under
treatment, and those who are psychotic
but who have not been diagnosed.
It is not too difficult to determine the
approximate number of psychotic pa-tients
in a commimity. Records of those
committed to mental institutions are
available in the office of the clerk of
the court. Certain cases being treated
in private institutions are not recorded,
but this number is relatively small. The
number of new patients who require
admission to a hospital each year is
approximately 75 per 100,000 population.
Most of these require treatment for a
year or more, some for much longer,
and many for life. Thus the care of the
psychotic patient becomes tremendously
important. No other single medical
problem is of such concern to the com-munity.
While the incidence of tuber-culosis
is close to that of psychosis,
the shorter hospital stay and the higher
recovery rate of tuberculosis patients
make this disease second in importance.
Let us look for a moment at the
problem the psychotic creates in the
community. Considerable stigma is
attached to mental disease, and people
are still reluctant to acknowledge that
a member of their family is insane.
They tend to delay treatment imtil it
becomes absolutely necessary, and even
then try to keep it as secret as possi-ble.
Page 4 The Health Bulletin April, 1956
Pui-thermore, the average individual
is poorly informed as tx> the early
symptoms of insanity. Yet the p>atient
rarely has any insight into his con-dition
and must depend on his relatives
and friends to make or suspect the
diagnosis and get him under treatment.
Consequently, the diagnosis is frequent-ly
delayed until the disease has ad-vanced
beyond the early stages and the
patient has become immanageable.
Only then does the family reluctantly
accept his condition and recognize their
need of advice. Usually they consult
the family doctor, who all too often is
not able to give much help. The aver-age
physician is not well acquainted
with the various types of mental illness
and has little interest in such patients.
As a rule general hospitals will not
accept psychotic patients for treat-ment,
and it is often diflficult to make
a proper diagnosis in the home. As a
result, many patients have to be con-fined
in local jails, which, of course,
lack adequate diagnostic and treatment
facilities. Treatment is thus further de-layed
and the chances of arresting or
curing the diseases are greatly dimin-ished.
Not only is diagnosis delayed, but
often facilities in state hospitals are not
readily available, and it is necessary to
keep the patient confined in jail for a
period of several days or even weeks.
This situation usually serves to aggra-vate
his mental disorder.
Most psychotic patients are treated
in our state psychiatric institutions,
and a good percentage are eventually
returned to the community from which
they came. Unfortunately, little or no
follow-up facilities exist. Almost no
social work is done, and the patient re-turns
to the same home and com-munity
problems that helped to bring
about his break-down in the first place.
Frequently the family has not been told
how to help him re-adjust to home and
community life, and there are few
clinics where he can continue to re-ceive
psychiatric help and guidance.
For this reason, a relatively large num-ber
of patients suffer unnecessary re-lapses
and have to be re-admitted to
the hospital.
Emotionally disturbed children
Community interest was most high in
regard to children with emotional or
personality disturbances so severe as to
interfere serioiisly with their adjust-ment
to school and family life.
Unfortunately, it is almost impossible
to evaluate this problem statistically.
It is certainly widespread. One pedia-trician,
on being asked what percentage
of his practice consisted of emotional
problems, replied that at one time or
another every child needs guidance or
help with this type of problem; how-ever,
only about 5 per cent of his pa-tients
came to his office primarily be-cause
of emotional disturbance.
In a typical community the juvenile
court handled 550 cases per 100,000
population; however, in only 135 cases
was the child involved considered to be
definitely delinquent. Despite the in-terest
of parents, schools, child guidance
clinics, and so forth, exact figures are
not available. We were interested in
finding out what the community con-sidered
were the causes of delinquency
and emotional problems in children.
The majority seemed to blame the fail-ure
of the family and the community
toward the child. It was frequently
pointed out that physical and mental
handicaps were also a big factor. Most
communities appear to be much better
able to handle the problem child than
they are the psychotic patient.
An unfortunate misconception in re-gard
to child guidance clinics seems to
exist in many communities. Unin-tentionally,
the pubUc has been led to
expect more from such clinics than
they can possibly offer. In fact, many
people seem to think that the estab-lishment
of a clinic will solve all their
mental health problems. They have
worked to establish clinics with this
idea in mind, only to find that the
cUnics were unable to care for any-thing
like the number of children need-ing
help. This, of course, is no fault of
the clinic; but the public should be in-formed
as to what a given clinic can
do, and should not be led to expect
miracles.
In setting up a child guidance clinic
April, 1956 The Health Bulletin Page 5
in an area, it would appear wise to let
the public know beforehand that a
clinic designed to meet the needs of
50,000 or 75,000 people cannot be expect-ed
to serve a quarter of a million
population. This is what has happened
in several areas in North Carolina.
Psychoneurotic adults
Adults with psychosomatic and psy-choneurotic
symptoms severe enough to
incapacitate them partially or com-pletely
were of little interest to the
community generally; however, these
persons were of considerable concern to
their families and to physicians. Such
illnesses should probably be regarded
as having both physical and emotional
aspects. It is impossible to determine
the number of individuals who fall into
this classification. Many general prac-titioners
say that from 30 to 50 per
cent of their patients have illnesses of
this type. Some clinics report that from
60 to 70 per cent of their patients come
primarily because of psychosomatic
symptoms. Actually the figure is prob-ably
much lower than indicated be-cause
patients of this type tend to
drift from one doctor to another and
remain almost constantly under medi-cal
care. Most doctors easily recognize
these patients, but few are inclined to
give the necessary time for handling
such cases properly. The number re-ferred
to psychiatrists is relativaly low
because of the scarcity of psychiatric
help and the high cost of treatment.
Mentally retarded children
The number of mentally deficient, or
retarded, children depends entirely on
the method of the classification used,
and may vary from 2 or 3 per cent to
10 per cent of the total chUd popula-tion.
The number of severely retarded
children is relatively low, and the
diagnosis is easily made. At present
little can be done for these children,
and they become candidates for in-stitutional
care.
The larger group of less retarded
children, probably approaching 8 to 10
per cent of the population, presents a
greater problem. They are unable to do
normal school work or enter any of the
skilled trades or professions, and are
therefore more likely to become delin-quent
or emotionally disturbed. Medical
treatment up to now has little to offer;
however, if mental retardation could be
recognized early and special education-al
and vocational provision made, the
community's problem would be consid-erably
lessened and many potential de-linquents
and petty criminals might be
made into useful citizens. Early recog-nition
and the provision of special
therapeutic and educational facilities
seem to offer the only answer at pres-ent.
Most communities seem to under-stand
the problem of mental retarda-tion
and are trying to do something
about it. However, the high cost and
lack of trained personnel in our school
system make progress slow.
Special problems
Psychopathic and constitutionally
inadequate personalities, chronic alco-holics,
mentally deficient adults, and
deteriorated cases create widespread
and distressing social problems. The
drur&ards, the ne'er-do-wells, the petty
criminals are encountered in every
community. They clog the courts and
sweU the relief rolls of the welfare de-partments.
They are everybody's con-cern,
but the public attitude is still
largely one of contempt and hopeless-ness.
In recent years Alcoholics Anony-mous
has done some excellent work in
rehabilitating the chronic alcoholic.
Clinics are now being started in some
areas to which alcoholic individuals can
come for medical, psychiatric, and
social service. The results have been
promising, and the public attitude to-ward
the alcoholic is changing.
The psychopathic, mentally retarded,
deteriorated cases are less hopeful. Psy-chiatric,
psychologic, and social studies
of these individuals, with records avail-able
to courts, welfare, and social ser-vice,
would be of help. Mental and
vocational evaluation could then be
made and possibly some type of super-vision
devised to keep many of them at
work and out of mischief. Supervised
Page 6 The Health Bulletin April, 1956
workshops where they could be kept in-definitely
might be set up. No one seems
to have a ready or easy answer.
Resources and Needs
The second part of our survey was
aimed at determining the resources and
needs for a community mental health
program. Since these vary considerably,
it was obvious that no one cormnunity
could be used as a basis for a study of
this type.
When this study was completed, we
realized that our findings were quite
similar to those obtained by the De-partment
of Mental Hygiene of New
York State and published in 1954. We
are therefore quoting extensively from
the New York report, "New Program
for Community Mental Health Ser-vices,"
noting where our findings vary.
We believe that the similarities be-tween
the two studies indicate that
mental health programs and problems
throughout the country are very much
alike.
. . . Nowhere in the State (New
York) were there adequate services at
the community level . . .
Services were uneverxly distributed
throughout the State. Except for a
few localities, mental hygiene cUnics
were the only mental health service
and the range was from one team for
30,000 people to one team for 353,000.
(Corresponding figures in North Car-olina
range from 400,000 to 700,000.)
At the local level, there exists no
single governmental agency charged
with responsibility for community
mental health. Significant parts of a
total mental health program are pro-vided
in many communities by educa-tion
authorities, by welfare officials,
by public health departments and by
courts, but nowhere is there a central
planning body for mental health ser-vices.
The result is overlapping,
duplication, and gaps in service, and
overextension of their programs by
some agencies.
Fragmentation of services at the
local level was aided by the fact that
financial support, although limited,
was available from a number of state
departments and agencies . . .
The mental hygiene clinic is the
community service which is in great-est
demand at the present time. This
is a relatively high per capita cost
service requiring psychiatrists, psy-chologists,
and psychiatric social
workers as the nucleus for the clinic
team. This high cost coupled with the
shortage of trained personnel makes
it necessary to plan services for fairly
large population groups.
In 1948, the former Federal Security
Agency recommended a ratio of one
psychiatric clinic per 100,000 popula-tion.
However, recent experience in
the operation of community mental
health clinics indicates that a more
realistic estimate of need may be one
full-time chnic for each 50,000
people . .
Any permanent program must take
into account the fact that, up to the
present, mental health services have
been developed by a variety of public
agencies and by a large number of
voluntary organizations. The present
inadequate level should not be wor-sened
by setting up a system which
would compel the giving up of any
existing qualified service. Moreover,
comprehensive programming for com-munity
mental health requires the
combined efforts of health, education,
welfare, judicial, and correctional
agencies, both public and private. It
is equally true, however, that there
is an urgent need for coordination
and integration by a single, responsi-ble
agency of local government . . .
There are five categories of com-munity
health services.
The first category is the one which
includes the greatest volume of ser-vices
outside the hospital. These are
involved with the process of making
an early diagnosis and providing early
treatment for individual cases of
mental disorder. In this category may
be included all of the mental hygiene
and child guidance clinics, in-patient
psychiatric services in general hos-pitals,
and the case finding efforts of
school systems, welfare agencies and
public health departments.
April, 1956 The Health Bulletin Page 7
The second category of service in
the community is that of rehabilitat-ing
the discharged or convalescent
patient from the mental hospital. The
after care clinic system has grown up
to a remarkable extent and covers
most of the communities of the state.
Although there are weaknesses in the
present intensity of rehabilitative
services to convalescent and dis-charged
patients, nevertheless an
enormous number of people are seen
every year in the after care clinics of
the state hospitals. In some com-munities
there are the begiruiings of
locaUy operated programs for re-habilitation,
particularly for discharg-ed
patients. (Our rehabilitative and
foUow-up services on both the local
and state level seem to be inferior to
those of New York State.)
A third category of community
mental health services may be label-ed
consultative. These are services
rendered by trained mental health
personnel to professional staffs of
other agencies such as welfare de-partments,
schools, courts, public
health departments and so on. They
deal with questions regarding the
mental status and the probable
abilities of an individual to fit into
the usual practices of the agencies
seeking the consultation.
A fourth category may be called
educational. Under this heading may
be included all those activities carried
out by mental health personnel to
communicate to other professionals
and to the general public what has
been learned from the clinical re-lationships
of mental health person-nel
regarding the problems of human
personality. These activities are di-rected
toward teachers, physicians,
ministers, parents, policemen, and all
other individuals who have, because
of their occupational or other rela-tionships,
special responsibilities for
the welfare and the mental health of
other persons. This field of mental
health education has only begun to
develop. There are many untapped
areas of work, areas where almost
nothing has been done systematically
up to the present time to improve the
understanding of occupations which
have a crucial relationship to the
thinking and feeling of people about
personality.
The fifth and last category of com-munity
mental health services may be
called prevention. At the present time,
it is the least voluminous of all of
the mental health activities, although
it is probably the most important. It
is true that all of the four categories
previously mentioned have been con-sidered
to be preventive or prophylac-tic.
This fifth category, however,
refers to specific efforts so to deal
with facts of community life as to
reduce the frequency with which
personality disorders occur. Two gen-eral
divisions of this category may be
described—those where the disease
has an organic cause which Is pre-ventable;
and those where we believe
the disease has a psychological cause.
With respect to the first division, pre-ventable
causes can be grouped into
travuna, infection, malnutrition and
poisoning. Examples are venereal
disease control programs, the problem
of rubella diiring early stages of preg-nancy,
the adequacy of nutrition,
during pregnancy, the problem of
minimizing compUcations of brain In-
Jiury, and the treatment of the in-fections
of childhood like measles so
as to avoid encephalitic complications
In the matter of psychological causa-tion,
there Is need, for example, to be
concerned with the maintenance of
the primary relationship a young
child has during the first years of
life. Prevention here encompasses the
implications of maternal separation,
of adoption ajid child placement prac-tices,
and of visiting regulations on
the pediatric wards of general hos-pitals.
No community can say that it has
a complete community mental health
program If tt does not take into con-sideration
all five of these activities
and If there is not one agency and a
group of people professionally pre-occupied
with the problems of seeing
to it that all five of these categories
Page 8 The Health Bulletin April, 1956
of services are provided to the people
of the community to the extent now
possible.
To these needs we have added a
sixth category which could be labeled
statistical data. Such data are needed
for several reasons. It is necessary if
the community is to understand and
appreciate its immediate problems in
mental health, as well as in setting up
a well planned program. It is also
necessary for establishing base lines for
comparison with future statistical data
to determine trends in mental health
problems. In no area in the local com-munity
did we find a serious attempt to
compile statistical data on mental
health, even though in some instances
such information and records could be
rather easily obtained. For example,
the clerk of court's office has records of
admissions to our state institutions for
the treatment of insanity. The welfare
department has records of juvenile de-linquency,
admissions to correctional
institutions, feeble-mindedness, and so
forth. It would appear that the com-pilation
of such data is essential to the
development of a good community
mental health program.
How Well Are our Present Needs
Being: Met?
In an effort to answer this question,
two simple studies were made. The
records of admissions to our state hos-pitals
for the past year were surveyed
to find out whether or not the patients
had been seen by psychiatrists and if
they had received proper diagnosis and
treatment prior to committment. It was
found that 6 per cent had been seen by
psychiatrists and could be classified as
having had adequate study and treat-ment.
Nineteen per cent had been seen
by a psychiatrist in consultation only,
and apparently to confirm the diagnosis
and sign commitment papers. Seventy-four
per cent had not been examined
by a psychiatrist at all, and apparent-ly
few, if any, of these had received
adequate study or treatment.
The second study was carried out by
sending a questionnaire to a small
group of physicians. Although the group
was small, it was designed to represent
a cross-section of the medical profes-sion.
The questions asked were: (1)
"What percentage of the patients you
see in your office do you feel could be
materially benefited by psychiatric
treatment?"; and (2) "What percentage
of the patients you feel would benefit
by psychiatric treatment are actually
referred to psychiatrists?" As was to be
expected, the number of patients classi-fied
as needing psychiatric treatment
varied considerably, depending on the
type of the physician's practice. Thus,
the general surgeon said approximately
10 per cent, while the replies of the
internists and general practitioners
ranged from 30 to 40 per cent. The
over-all average was about 25 per cent.
The percentage of patients actually re-ferred
to psychiatrists did not vary so
widely. Among white physicians the
proportion ranged from 1 to 2 per cent;
among Negro physicians, 0.1 to 0.5 per
cent.
As a third measurement, we decided
to consider the proposed mental health
clinic set-up in North Carolina on the
basis of population the clinics will have
to serve, and the estimated number
that such clinics can serve adequately.
Eight clinics must serve the entire
population of the state—approximately
4,500,000. This would mean that each
clinic must serve about 550,000 persons,
or from five to ten times the number
it could be expected to serve adequately.
It seemed safe to conclude from evi-dence
of this type that mental health
services are inadequate, and even
though the number of psychiatrists
and other workers may increase con-siderably
over a period of years, at no
time in the foreseeable future will per-sonnel
be commensurate with the needs.
Summary and Conclusions
In this survey we have tried to ap-proach
mental health from the stand-point
of the local community and have
considered three different aspects of
the problem. What are the problems of
mental health as the comjnunity sees
them? What are the mental health
needs of the local community? How well
are these needs being met?
We realize how inadequate this sur-
Ap7il, 1956 The Health Bulletin 9
vey has been. We realize that it has
not been conducted in an accepted
scientific manner and that it has not
really revealed anything that we did
not know before. We believe, however,
that it has some value and that from
it can be drawn certain conclusions
which may help to clarify our thinking
and planning in mental health.
1. Education is one of the primary
needs in mental health.
a. Although the psychoses constitute
one of the most common serious dis-eases,
the public is poorly informed
about the early signs and symptoms
and how to obtain early diagnosis and
treatment. This situation is made worse
because most mentally ill patients are
taken away from the local community
and treated in state institutions. For
this reason, the public does not ap-preciate
the extent and seriousness of
mental disease. The average hospital
does not provide diagnostic and treat-ment
facilities. As a result, general
practitioners have little interest in the
handling of mentally ill patients. These
factors have caused mentally ill pa-tients
to receive late and inadequate
treatment and care.
b. Greater stigma is attached to
mental illness than to any other disease,
with the possible exception of syphilis.
Why? There are several partial answers.
The public has been led to believe that
mental illness is something mysterious
for which there is no explanation.
People associate it with some hidden
heredity taint, some confused Freudian
concept or sex obsession, which really
means nothing to them but which
serves to attach a high degree of
stigma to the condition. Would it not
be much simpler and wiser to admit
that we do not know the cause or
causes of mental illness any more than
we fully understand the causes of
rheumatoid arthritis or atherosclerosis,
but that pathologic and physiologic
causes exist just as in other diseases?
It has not been long since the causes
of rickets, diabetes, and paresis were
unknown.
2. Our present approach to mental
health problems is unrealistic. The
statement, "too little too late," could
be applied to our thinking and plan-ning.
We cannot hope to have, in a
reasonable time, enough trained per-sonnel
or funds to do the job with our
present plan of attack. Obviously, we
must explore ways and means of
achieving a mass approach. We should
seek advice and help of other groups
particularly general practitioners, wel-fare
departments, and schools.
3. Each local community should in-vest
some responsible group or board
with the authority to plan and carry
out a mental health program. Up to
now, various agencies and various
groups have attempted, in a limited
way, to deal with the problem. Results
have not been good and imless the re-sponsibility
is assigned to one group,
future planning and coordination will
be inadequate.
4. At present relatively little atten-tion
is paid to the psychotic patient in
the local community. Such patients are
often confined in jail, where diagnostic
and treatment facilities are lacking and
where the environment tends to aggra-vate
the patient's condition. General
hospitals should provide diagnostic and
treatment facilities for mental patients.
5. Local communities have made
relatively little effort to gather or
analyze statistical data on mental
health problems. It would not be diflEl-cult
for local health departments or
other agencies to compile statistics re-garding
mental illness and other phases
of mental health. Such an effort would
serve to focus community interest on
the importance of these problems and
would be of considerable help in
evaluating trends in mental disease in
the future.
6. Finally, we feel that we know only
a few of the answers to the problem of
mental health and would suggest that
the Academy of Preventive Medicine
continue its study.
10 The Health Bulletin April, 1956
NOTES AND COMMENT
BY THE EDITOR
PEDIATRICIAN RECOMMENDS
"FENCING IN" TODDLERS
An Evanston, 111., pediatrician has
recommended that preschool children
be separated from "adult gadgets and
trouble" for at least half of their play
time.
Dr. E. Robbins Kimball said this will
help the child in his adjustment and
adaptability by allowing him to escape
the adult "no" for part of his time and
by slowing down the expansion of his
world to the point where he can handle
it.
A child does not really understand
what belongs to him and what belongs
to his parents until he is four years
old. Until then he should be relieved of
the responsibility of not touching the
possessions of adults for half of his
playing hours (four hours a day), Dr.
Kimball said in the Journal of the
American Medical Association.
Because parents cannot live in a
nursery, Dr. Kimball suggested that the
child be separated from the adult
world by means of a play pen, gated
room or porch, fenced yard, or nursery
school, depending on his age.
Such "compartmentation" gives ner-vous
mothers relief and decreases the
number of household accidents. In
addition, its prevents the child from
developing habitual patterns of resis-tance
to adults as they try to direct
him.
In a study of 363 children, followed
for five to 10 years, Dr. Kimball found
that a child adapted to new situations
more readily as soon as he escaped the
adult "no" for half of his play time. In
fact, toddlers' adaptability increased
fourfold with "fencing in."
He also found that being a first child,
having nervous parents, and not being
breast fed, had an adverse effect on
the child's adaptability.
Many first children had difficulties
in adjustment because their parents,
being unfamiliar with growth, expected
them to perform at about twice their
developmental level.
"Many of these parents would have
been indignant if a school system had
tried to force their nine-year-old child
to master a topic such as calculus. Yet,
many persisted in teaching their two-year-
old the differences between mine
and thine, not to spill food, not to
suck his thumb, to give up his bottle,
and many other habits that he was not
ready to master until twice that age,"
he said.
Dr. Kimball found that children who
had trouble adapting "looked with
questioning, frequently with appre-hension,
and too often with great fear
at all adults" during examinations.
Others, instead of being cautious, were
boldly aggressive and ignored direction.
Children who showed more adaptability
were calm and smiling and enjoyed the
examination.
PYORRHEA REQUIRES BOTH
DENTAL, MEDICAL CARE
Diagnosis and treatment of bleeding
gums must be a cooperative project of
doctor and dentist, an editorial in the
Journal of the American Medical As-sociation
said.
"Periodontal disease (pyorrhea) is by
far the major cause of tooth loss In
individuals over 35 years of age," it
said. Inflammation of the gums is pres-ent
to some degree in most persons
who eat chiefly soft and cooked foods,
and gums may bleed from a variety of
causes, local or systemic.
Local irritation of the gums is al-most
always the primary cause, al-though
occasionally some underlying
systemic factor may cause bleeding in
the absence of local irritation. Most
frequent local causes are tartar ac-cumulation,
injury, abnormalities in the
bite, food impaction, and ill-fitting
dentures or fillings.
It would be a mistake, however, to
consider all gum bleeding as a sign of
uncomplicated gingivitis (inflammation
of the gums) or periodontitis (inflam-
April, 1956 The Health Bulletin 11
mation of tissue surrounding the tooth),
as is frequently done, the editorial
said. The bleeding may be a sign of
serious general disturbance, such as
scurvy, pellagra, diabetes, leukemia,
pregnancy, allergy, or lead, bismuth, or
mercury poisoning.
The editorial said that local treat-ment
by the dentist can correct the
mouth condition if there is no under-lying
systemic disturbance. But, if there
is an underlying cause, treatment of
that condition alone will not stop the
bleeding. There must also be local
treatment by the dentist.
Prescription of vitamin supplements
as the sole treatment for bleeding gums
is "irrational and ineffectual," he said.
Antibiotics may serve to relieve the
acute inflammation, but the condition
almost invariably returns as soon as
the antibiotic levels are no longer
effective. Removal of tartar and other
local factors is necessary to achieve
lasting effects.
Physicians and dentists must fre-quently
refer patients to each other for
dental or medical surveys, since the
best results in the treatment of py-orrhea
can be obtained only when all
the causative factors, usually more than
one, are discovered and treated, it said.
EARLY TRAINING MAY PREVENT
CHILD'S SPEECH DEFECTS
Guidance of mothers in the early
management of speech behavior of their
children may help prevent speech
defects in mentally normal children,
two physicians and a nurse said recent-ly.
A study of 290 mentally-normal child-ren
with speech defects was reported
in the Journal of Diseases of Children,
published by the American Medical
Association. It was done by Dr. Ben-jamin
Pasamanick, Columbus, Ohio,
Frances K. Constantinou, R.N., Balti-more,
and Dr. Abraham M. Lilienfeld,
Buffalo, N .Y.
In earlier investigations the physi-cians
found that childbirth abnormali-ties
are significant in the background
of cerebral palsy, epilepsy, mental de-ficiency,
and some childhood behavior
disorders. They thought speech defects
might also be related to such abnor-malities,
because specific injury to the
brain in adults has been reported to
result in speech defects and because
speech disorders are very common
among children with cerebral palsy and
mental deficiency.
Records of 290 children, born in Balti-more
since 1940, with speech defects
but without mental deficiency or cere-bral
palsy showed no more complica-tions
of pregnancy and delivery, pre-maturity,
or abnormal conditions of the
newborn than did records of a similar
number of normal children without
speech defects.
However, the discovery that there
were more twins and more later-born
(third, fourth or fifth) children in the
speech defective group suggests that
psychological and social factors play a
role in causing speech defects, they
said.
It is possible that twins who have
more contact with each other than with
older children learn from each other
immature, faulty, speech patterns which
become fixed due to their closeness and
mutual comprehension of their impair-ed
speech, the authors said.
It might also be that later-born
children develop speech defects because
of rivalries, disorganizations, and frus-tration
in large-family living. The im-patience
of older family members with
speech in the younger children or the
lack of attention from a busy mother
with several children might also con-tribute
to the production of speech de-fects,
they said.
The prevention of some of these
socially and psychologically disabling
disorders may lie in the guidance of
mothers in the early management of
their children, they said, adding that
further study of these factors is neces-sary.
The study was aided by a grant from
the Foundation for Mentally Retarded
and Handicapped Children of Balti-more.
12 The Health Bulletin April, 1956
DOCTORS NOTE REDUCTION IN
OPERATIVE RISKS FOR AGED
A comparison of records for the last
decade with those of 20 years ago show
the falsity of the adage "the older the
person, the greater is the operative
risk."
Drs. Carl A. Moyer and J. Albert Key
found that for many operations the
risks now are the same for persons
over 60 years as for persons under 60.
Survival rates for all ages have in-creased
greatly in the last decade, and
especially for the older group, they said
in the Journal of the American Medical
Association.
One reason for the change is im-proved
treatment of postoperative in-fection
through the use of antibiotics.
This is particularly true for cholecys-tectomy
(removal of the gallbladder)
and appendectomy, which used to have
high death rates because of infection.
The outlook is now about as good for
old as for young patients.
Greater skill in administering anes-thetics,
fluids, and blood have also
helped to reduce risks. Anesthesia,
long considered an important factor,
actually is comparatively unimportant,
except in operations which otherwise
are of little risk, such as those for
hernia, appendicitis, and the thyroid
disorders, they said.
Their study showed that aging itself
is not "an insuperable barrier" to per-forming
needed surgery on more pa-tients
without pushing over- all risk be-yond
an acceptable level, they said.
The extent of the surgery is not as
important in determining operative risk
among the aged as is the duration of
physiological upset before, during, and
after the operation, they said. Although
it is hard to evaluate the degree to
which a patient's strength has been
undermined by a long period of pre-operative
illness, this is important in
determining the risk.
Some rather involved operations, such
as removal of a breast or cholecystec-tomy,
have low operative risks because
the following physiological upset is re-latively
brief, while some less complex
operations with long recovery periods
have significantly higher risks. The
operative risks are similar for both old
and young in thyroidectomy, hernia
operations, and partial removal of the
stomach for duodenal ulcers, they said.
Heart-lung diseases also have become
less important in determining operative
risk for the aged. In fact, except for
some very serious conditions which in-crease
the risk regardless of age, the
cardiac-pulmonary condition of the
aged patient has little effect on opera-tive
risk, they said. Conditions which
have an effect at any age are angina
pectoris, repeated myocardial infarction,
uncontrolled cardiac failure, and malig-nant
hypertension.
REASONS GIVEN FOR DELAY
IN SEEKING SURGICAL CARE
A new explanation of the familiar
experience of putting off a visit to the
doctor even when danger signals are
present was given recently by a group
of Cincinnati researchers.
One of their major findings in a
survey of Cincinnati surgical patients
was that people do not delay just be-cause
they aren't aware of what the
danger signs mean.
In fact, among 200 patients the per-son
who was totally ignorant of the
importance of danger signals was "ex-tremely
rare," indicating that the medi-cal
profession and medical publicists
have done a good job of educating the
public, they said in the Journal of the
American Medical Association.
Of the 200 patients surveyed, 23 had
no opportunity to delay seeking surgi-cal
treatment, and no information was
obtained on 11. Of the 166 patients who
had an opportunity to delay, 71 did so,
they said.
Many of these delayed, not because
of ignorance of the danger signs' mean-ing,
but because of various personality
and emotional factors, the survey show-ed.
In addition, it disproved several other
reasons frequently given as causes of
delay. Delaying patients were of all
ages—not "young and foolish" or "old
and fatalistic." There was no difference
in intelligence between those who de-
April, 1956 The Health Bulletin 13
layed and those who did not. Sex was
not a factor; men and women were
almost equally represented in both de-lay
and nondelay groups.
The survey neither confirmed nor
denied the idea that cost influences de-lay.
All of the patients were in a hos-pital
which provides care even for those
who cannot pay, but some might have
delayed because they were ashamed of
having to accept free treatment.
Their study also disproved the idea
that delay is a symptom of one or
another specific type of mental illness.
There was no significant difference in
the psychiatric diagnoses of delayers
and nondelayers.
The researchers did find, however,
that delay resulted from various con-scious
and unconscious factors operat-ing
before, during, and after recogni-tion
of a sign or symptom. The kind of
illness suffered could play a part in
the delay, but was not by itself a
sufiicient reason, they said.
While the medical profession and
publicists have been successful in reach-ing
most persons with straight informa-tion
about disease, there is still much
to be done to overcome these emotional
factors causing delay, the authors said,
suggesting that there be some changes
in the emphasis in public education
and that more attention be paid to the
emotional factors during medical and
surgical treatment.
Making the report were James L.
Titchener, M.D., Israel Zwerling, M.D.,
Ph.D., Louis Gottschalk, M.D., Maurice
Levine, M.D., William Culbertson, M.D.,
Senta Cohen, Ph.D., and Hyman Silver,
Ph.D., from the departments of surgery
and psychiatry. University of Cincinnati
College of Medicine. Dr. Zwerling is
now at Albert Einstein College of Medi-cine,
New York. The study was sup-ported
by a grant from the National
Institutes of Health, Bethesda, Md.
HARDENING OF ARTERIES
POUND IN ELEPHANT
Heart attacks resulting from the
effects of hardening of the arteries can
strike elephants as well as men and
dogs, three California doctors said.
They reported an autopsy on a fe-male
Indian elephant who died of acute
heart failure secondary to severe
arteriosclerosis in many small arteries
aroimd the heart.
According to the physicians, their re-port
in Archives of Pathology, publish-ed
by the American Medical Associa-tion,
is the first one describing arterio-sclerosis
in elephants. It has previously
been found in humans, cats, dogs, pigs,
birds, chickens, and cows.
Few autopsy reports on elephants
have been made, but studies go back
to ancient Greece and Rome, the
authors said. Both Aristotle, the Greek
philosopher, and Galen, a Greek phy-sician
who lived in Rome about 200
A.D., reported elephant studies, with
Galen describing a heart condition as
"a bone in the heart."
The San Francisco elephant was at
least 47 years old and had lived in the
San Francisco Zoological Gardens since
1925. The animal, which appeared
healthy the night before death, was
found lying on its side and unable to
rise a few hours before death.
Autopsy showed severe arteriosclerosis
of the major arteries. In the small
coronary arteries, the disease was
similar to that observed in birds, dogs,
cats, and humans. However, deposits
of fatty substances, usually found In
the small arterial walls of humans
with similar disease, were absent.
Similar narrowing of the arteries with-out
fat deposits may occur in old dogs
and cause sudden death, they said.
The physicians said that heart fail-ure
occurred in the elephant apparent-ly
because the narrowing of the small
coronary arteries diminished the blood
flow to the heart. The same thing has
happened in human beings. Not only
are the physiological occurrences
similar in man and the elephant, but
the same terms—"acute myocardial
failure" due to "coronary insufBciency"
—are used in autopsy reports to describe
the conditions.
Drs. Stuart Lindsay, San Francisco,
Richard Skahen, Oakland, and I. L.
Chaikoff, Berkeley, from the depart-ments
of pathology and physiology of
14 The Health Bulletin Apnl, 1956
the University of California School of
Medicine, did the work under grants
from the Alameda County Heart As-sociation
and the United States Public
Health Service.
SOAP, FACE TISSUES MAY
CAUSE DERMATITIS
It apparently isn't possible to put out
a product for use on the skin that
won't cause somebody, somewhere, to
break out in a rash, according to two
reports.
A new product might be used safely
by two million people but not by the
one w^ho is sensitive to something in it.
Doctors treating hard-to-explain skin
troubles often have a hard time find-ing
a solution unless they can discover
the individual's particular sensitivity.
The list of possible causes of sensitivity
is long.
Two more items—an antiseptic soap
and facial tissues—were added to the
list by reports in the Journal of the
American Medical Association.
The report by Irvin H. Blank, Ph.D.,
of the Harvard Medical School derma-tological
research laboratories, Boston,
said that ordinary soap generally won't
bother anybody. But excessive use
might be partly responsible for skin
trouble or aggravate a preexisting skin
condition among a few people. And
some rare individuals have been found
to be sensitive to dyes or perfumes in
otherwise harmless soap. Dr. Blank
said he has now found this is also true
of a soap containing a chemical intend-ed
to make it antiseptic.
In the other report, Drs. Samuel M.
Peck and Laurence L. Palitz, New York,
said so-called "wet strength" facial
tissues, which have been treated to
make them more moisture resistant,
might bother some people.
Dr. Blank said the presence of a
chemical (tetramethylthiuram disulfide)
in an antiseptic soap causes rashes
among persons already sensitive to the
chemical from contact with rubber
products containing it. However, few
other persons appear to be sensitive to
the chemical in the soap. In a 17-
month period only about one case of
dermatitis for every two million bars of
soap sold was reported to the manu-facturer,
who has kept close watch on
the situation. Dr. Blank concluded that
there appears to be no more allergic
reactions to the soap among ordinary
users than there were before the addi-tion
of the chemical.
The New

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OnH)et0itp of l^ottfj Carolina
This Book Must Not Be Taken
from the Division of Health
Affairs Buildings.
This JOURNAL may be kept out TWO DAYS,
and is subject to a fine of FIVE CENTS a day
thereafter. It is DUE on the DAY indicated
below:
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Published monthly at the o6fice of the Secretary of the Board, Raleigh, N. C.
Entered as second-class matter at PostofBce at Raleigh, N. C. under Act of August 24, 1912
{
Vol. 71 ^- JANUARY, 1956 No. 1
CLEVELAND COUNTY HEALTH CENTER, SHELBY, NORTH CAROLINA
THE NORTH CAROLINA STATE BOARD OF HEALTH
RADIO BROADCASTS
Station WPTF, Raleigh, North Carolina—Saturdays 1:20 p.m.
Station WWNC, Asheville, North Carolina-Saturdays-9:15 a.m.
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Hubert B. Haywood, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
Ben J. Lawrence, M.D Raleigh
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta HUlsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, D.D.S., Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M. Jarrett, B.S., Director Sanitary Engineering Division
Fred T, Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departments or on
written request.
CONTENTS Page
Public Health And The Doctor In Civil Defense 2
The Public Health Nurse's Contribution To
The Mental Health Of A Community 6
PUBLIC HEALTH AND THE DOCTOR IN
CIVIL DEFENSE
By C. B. KENDALL, M.D.,
State Board of Health, Raleigh, N. C.
If we have not already done so, it is warfare. He possesses a fleet of over
absolutely essential that we now accept 1,000 bombers capable of delivering
the premise that civil defense—defense CBR agents to any city in this country
against chemical, bacteriological and and returning to base, non-stop. His
radiological agents and the mainten- philosophy of offensive warfare is
ance of a constant state of prepared- definitely based on the devastating
ness against such agents—is a way of sneak attack with thermonuclear wea-life
and a way of life that we must pons. He is capable of doing just that
observe so long as there is necessity if and when the occasion demands and
for any element of national defense, presents. His hand may be restrained
Our principal potential enemy has the by the knowledge that retaliation
knowhow and material for this type of would be immediately forthcoming—but
January, 1956 The Health Bulletin
he need not fear or prepare for such
devastating damage as we must expect
because of the wide and secret dis-persal
of his heavy industry and vital
facilities. We hope that there is a
tender heart behind recent pacific
gestures. We have reason from past
experience to believe otherwise. The old
adage advises us to beware the Greek
bearing gifts. On the day of Pearl
Harbor there were in Washington two
upper-crust Japanese diplomats bearing
olive branches. The day before the
Berlin blockade the city was visited by
sweet- talking emissaries of the Soviet.
Incidents of the dove of peace in one
hand and the spike-studded mace in
the other are evident from day to day.
In 1931 Manuilsky of the Lenin School
of Political Warfare explicitly an-nounced
the poUcy of subversive in-filtration,
lulling the bourgeois into a
sense of security with concessions and
peaceful gestures, and annihUatuig him
when properly softened—this entire
process requiring perhaps 20 to 30
years. There has been no indication of
a change in over-all policy—and the
time may be nearer than we think.
Kaganovich has recently predicted
worldwide victory for Communism in
this century. The recent Geneva con-ference,
of which we expected much,
has, with great travail, spawned a dead
herring.
No setup of civil defense can prevent
the blow from falling. It can, however,
definitely soften it and, if at all effec-tive,
prevent ultimate total paralysis
or complete annihilation. It can help
the survivor to survive—and that, in
brief, is the function. To be able to do
this requires planning, research, organi-zation,
training, the consecrated efforts
of many and the genuine interest and
cooperation of all. This is everybody's
business. The task is tremendous—but
it can be accomplished. The problems
are knotty—but they can be solved.
Preparation and prevention are expen-sive,
and substantial support is requir-ed.
When it is not forthcoming, bricks
must be made without straw—and Mr.
John Q. Publi9«hgs>rfretue|itly demon-strated
that, with leadership and guid-ance,
he can do just that.
It was my good fortune to be able to
attend a two-day seminar put on in
March by the U. S. Public Health Ser-vice
on the fimctions of public health
in civil defense. This was attended by
J. M. Jarrett, our engineer, Dr. Ben
Drake, Mrs. Kneedler, Steve Marsh and
Dr. George Watson, of Durham. We
came away with the feeling expressed
by Mr. Jarrett that, while every detail
had not been covered, we had received
a bad scare, and he has done some-thing
about it in carrying the word to
his sanitarians by means of his district
conferences. We did not find the cover-age
in the program as bad as did a
recent participant in a civil defense
conference in South Carolina, who said
at the halfway mark that the program
was like a hoop skirt, covering every-thing
but touching no important point.
To public health has been definitely
delegated the maintenance of general
and environmental sanitation and dis-ease
prevention and defense against
CBR. The United States Public Health
Service acts as over-aU advisor and
assistant in planning, research, train-ing
and detection and is prepared to
give technical guidance in the prepara-tion
of shelters, protection of utilities
and restoration of facilities. To the
states is delegated the responsibility
for actually setting up proper plans
and organization and for carrying out
training. They are advised and aided
by the Regional set-up (for this
Region, in Thomasville, Georgia). The
lowest echelon is the local organization
and this is of course the most im-portant.
Since the development of the H-bomb
and as a result of studies of its
effects, attention has been sharply
drawn to the necessity for planning for
mass evacuation of whole commimities.
The radioactive fall-out from a modern
thermonuclear device released in Wash-ington
can affect a downwind area 200
miles long and 40 mUes wide. Unpro-tected
survivors of the blast in Wash-ington
would be generally subjected to
The Health Bulletin January, 1956
a lethal dose of radioactive substance,
which would be capable of causing the
death of fifty per cent of the inhabi-tants
of the Philadelphia-Trenton area
if unprotected and ten per cent of
those in New York City.
If warning is suflficient (and we hope
for an hour) many inhabitants can be
evacuated from a potential target area.
Such evacuation becomes easier from
an area in the path of fall-out, and,
with proper information, there will be
more time.
It requires little thought and imagi-nation,
however, to appreciate the
stupendous problem presented by a
rapid mass evacuation. To be prepared
for such, it is absolutely essential that
there be planning down to the last de-tail
and organization by precinct, ward,
street, block and family, with every
individual instructed thoroughly in
what to do, where to go and to whom
to look for orders. Every family should
have a least one thoroughly trained
member—and a survival kit. In the
exodus from the community minutely
detailed organization of transportation
and traffic is required. The proper
routes must be selected for the many
columns, and these must be finally
chosen with a knowledge of the direc-tion
of winds and fall-out and of the
width of the fall-out area. A temporary
staging area would probably be neces-sary
to evaluate all elements before the
final receiving area could be selected.
In such a movement public health and
medical personnel would face all the
problems of support in primitive condi-tions,
and a knowledge of elementary
and basic field sanitation and emer-gency
sanitary equipment, as taught
and used in the armed forces, would be
of tremendous value.
Every area and community that can
be possibly used for the reception and
care of evacuees must be thoroughly
studied for resources, those resources
listed and arrangement made for im-provised
and emergency supplementa-tion.
Exposure to radioactive material may
produce a variety of reactions from
mild tissue disturbance, through pre-cancerous
lesion, to tissue destruction
and death. Susceptibility to infection
is increased. Sublethal exposure of
evacuees becomes a public health prob-lem.
There are defensive measures of im-portance
where a blast is delivered
without warning. The survivors must
dig in and seek cover from fall-out.
Preparation for defensive measures
consists of the spreading of informa-tion,
recruitment of personnel and
training. Training in first aid and in
home nursing is important and must
be stressed and carried on with vigor
and wide coverage.
Teachers must be recruited ,from
those with knowledge of medical emer-gencies
and nursing. Instruction in aid
for radiological casualties will be im-proved
by the use of science teachers
and handlers of radioisotopes. Wardens
and sanitary personnel must become
familiar with the use of the Geiger
counter. A detection apparatus the size
of a cigarette package is being worked
out now with changes in the color of
fluid in tubes the diagnostic element.
We hope to have in the not too dis-tant
future a Geiger apparatus to be
placed in the hands of district sani-tarians
for demonstration and instruc-tion
of sanitary personnel in the five
districts. The efficacy of improvised
shelters should be stressed and plans
for them made available. The old vege-table
or root cellar with a three foot
roof of earth is a simple and effective
protection.
Biological warfare can be effective
against crops, domestic animals, hu-mans
and water and food facilities. It
is an agent that could be particularly
devastating against an uprooted and
primitively existing population. An in-vader
might choose to use it as being
less destructive of facilities in an area
that he plans to occupy. Surely some
rather exotic agent would be used, one
that is difficult of destruction, easily
grown and distributed and capable of
effect through various body systems.
Anthi-ax has been suggested as meet-
January, 1956 The Health Bulletin
ing most requirements, but such sug-gestion
has not been impressive to us
in this State who are aware of a
surprisingly small outbreak of the
disease among several hundred em-ployees
of a factory who worked for
some time with material and in an
atmosphere heavily laden with the
organism.
The thought of such an agent in
warfare is a peculiarly horrifying one.
If you wish to appreciate what epi-demic
disease can do in a commmiity
ignorant of the cause, unprepared and
thoroughly frightened and demoralized
reread the description of bubonic plague
in London appearing in the popular
novel "Forever Amber".
Essential in defense are facilities for
early recognition of the agent, early
diagnosis of disease and early report-ing.
Research is being carried out on
means for practically automatic detec-tion
of organisms. Local laboratories
must keep abreast of all advances and
there must be a network of sampling
facilities. All must bear in mind that
they can receive aid through State and
Federal agencies in event of necessity.
Plans must include arrangements for
the protection of utilities and other
facilities against overt or covert attack.
Stockpiling of drugs is an element of
all plans, and health departments must
be prepared to carry out emergency
sanitation measures.
Individuals may receive some pro-tection
from masks, clothing, shelters
and evacuation. After an attack comes
diagnosis of the agent, treatment of
casualties, education of the people in
the treatment and use of contaminated
supplies, decontamination with heat,
chemicals and soap and water and
disposal of unsalvagable material. Vac-cine
prophylactics may be indicated,
and the elaboration of polyvalent prod-ucts
is possible.
Most of us are somewhat familiar at
least with the possibilities of chemical
warfare and know that protection has
been devised. Such warfare has been
outlawed by civilization, but you must
note that we have continued to support
a chemical warfare component in the
armed forces.
The U. S. Public Health Service has
provided training facilities in the pub-lic
health aspects of civil defense in
the Advanced Civil Defense Center at
Atlanta and the Sanitary Engineering
Center in Cincinnati. Here courses of
varying lengths are available as are
extension courses, manuals and bro-chure
material. They are well worth
the consideration and patronage of all
of us.
In many endeavors of this life and
age it must be recognized that, if they
are to be carried out enthusiastically
and well, they will find some of their
most enthusiastic sponsors in the
women of the country. The American
Nursing Association takes an active
part in the councils of Federal Civil
Defense, and the North Carolina
Nui-ses' Association has an active civil
defense group headed by Mrs. Mary
Dunn of Watts Hospital. Plans exist
for the utilization of nurse power
through the military, civil defense and
the American Red Cross. A good pre-paration
for civil defense nursing
function for those nurses who can
qualify is a period of service in the
armed forces.
"Nm-sing During Disaster" is a bro-chm-
e that is available and instructive.
The point may be made here that the
term "disaster procedure" may be more
palatable than "civil defense" and cer-tainly
its more general use may pro-duce
more general interest inasmuch
as all the planning, organization and
training advised and carried out by
"civil defense" is intended also for very
practical application in catastrophes
that may be laid upon us other than
by an enemy invader.
The American Hospital Association
has a committee on mass casualty care.
What local organization and planning
has resulted, I do not know. It must
depend upon the alertness and en-thusiasm
of the local hospital adminis-trator
and his staff and upon the vigor
and foresightedness of the local direc-tor
of civil defense. Those administra-
The Health Bulletin January, 1956
tors I have questioned have no definite
plan.
Every hospital should have a written
and detailed plan for the handling of
mass casualties; for bed expansion; for
full use of facilities, key personnel,
volunteers. The plan should be adap-table,
should show specific job assign-ments
and should provide for relays
of work shifts, procurement and stor-ing
of supplies, triage, (sorting) with
admission and registration set up, and
evacuation. A blood bank program
should be prepared, and all personnel
should be trained for smooth-running
team work. Triage is extremely im-portant
and should be the function of
the most experienced staff surgeon,
who is prepared to set aside the case
with over half his body burned, who
will die anyway, and the patient with
one-tenth of his body surface involved,
who will get well anyway, and place for
definitive treatment those between
these extremes who can be saved by
treatment.
Every hospital should "mother" an
improvised emergency hospital set up,
manned by young people. It is, per-haps,
around the hospital with a de-tailed
written plan kept up to date that
organization of complete medical ser-vice
for disaster with utilization of all
professional disciplines may be best
effected.
We must depend upon local health
ofl&cers and their staffs to carry the
torch in preparedness for CBR De-fense.
Such preparedness is essentially
preventive medicine. All must discipline
themselves to maintain an interest in
preparedness for a situation that may
never come about. Public health per-sonnel
are accustomed to such disci-pline.
THE PUBLIC HEALTH NURSE'S CONTRIBUTION
TO THE MENTAL HEALTH OF A COMMUNITY
By RUTH A. GWYN,
Public Health Nurse, Forsyth County Health Dept.
Winston-Salem, N. C.
I would like to describe to you how
a public health nurse in our depart-ment
worked with a family which I
shall call the Blake family. The six-year-
old son, Jackie, was progressing
very slowly in school, and it was decid-ed
that a psychological test should be
done on him. The public health nurse
was requested to obtain the medical
and social history. The mother con-sented
and was cooperative but couldn't
come to the school for the conference.
She requested that the nurse inform
her of the results of this test, which
revealed that Jackie's I.Q. was quite
low and that he probably would reach
the limit of his learning capacity
around the 5th grade. The psychologist
advised the nurse to work with the
mother to help her xmderstand and
adjust to Jackie's limitations. Through
repeated visits the nurse was able to
guide her into giving him more under-standing
and into helping him more
with home work and also coimsel her
to lessen her pressure on him. The
school authorities later decided to re-tain
Jackie in the first grade. This was
extremely upsetting to him. The medi-cal
history had revealed that Jackie
had occasional epileptic seizui'es. These
became more frequent. The nurse ad-vised
Mrs. Blake to consult the child's
physician and the school principal. The
decision was then made to socially pro-mote
Jackie. His seizures immediately
became less frequent, his crying spells
ceased and his behavior became more
normal. This mother's response to the
nurse's guidance has become increas-ingly
rewarding. The nurse's confer-ences
with Jackie's teachers have help-
January, 1956 The Health Bulletin
ed ease tension between the home and
school. Mrs. Blake has a younger child
who appears to be even more retarded
mentally than Jackie. She has been
able to accept this child more easily
and with greater determination and
faith in her ability to help him. Her
keen interest in the nurse's visits, her
pride in reporting signs of progress and
her patience and faith have been most
gratifying.
Mrs. Blake has demonstrated no
attitude of rejection toward the nurse,
as was the case at first toward Jackie's
teacher. The nurse doubted that she
would be justified in spending extra
time and effort with this family, but
this experience has convinced her that
her time was—and still is—being well
spent in a supportive role with the
Blake family.
This example serves to show the kind
of contribution the public health nurse
with no specialized training may make
to a family.
The supportive service of the public
health nurse to the families of mental-ly
ill patients, as well as to the patients,
is obviously becoming more necessary.
Increasing emphasis is being focused on
this phase of work in the generalized
program of public health nursing. We
have been—and are—doing mental
health nursing every day, but we
probably have not recognized it as
such.
Public health ntirses have perhaps
been reluctant to accept this role be-cause
of their feelings of inadequacy
and lack of preparation in this area.
This, nevertheless, should not block
them in their efforts to see the patient's
and his family's mental health needs
and to broaden their services to include
more mental health teaching. Because
of her skill in human relations, her
training and experience with other ill-nesses,
it is logical to expect her to
offer some help to families in which
there is mental illness.
It is not expected of public health
nurses that they give psychiatric
therapy to the patient or the family,
but there is some help which all nurses
who work in a generalized program
should be able to render. It is a
recognized fact that a public health
niu-se who has had specialized training
in mental health is qualified to give the
greatest help, but one writer has ex-pressed
the feeling that the niu-se with-out
the formal training may very
effectively relate herself to the patient
and family in a less technical way,
since she may, more or less, be con-sidered
a big sister to some families.
Should she not trust her own informa-tion
and impressions as she does in her
other activities, such as helping a
tuberculosis patient accept his diagnos-is?
Isn't she quick to sense a mother's
rejection of her pregnancy? Does she
not then try to direct her efforts to
help her accept the role of mother-hood—
realizing the effect her attitude
has on the expected baby and the
whole family? The nurse recognizes the
importance of the mother's mental
health as well as the necessity for
getting good physical care.
Probably one of the most important
qualifications a nurse could have is her
sincere interest in the promotion of
good mental health and her desire to
make her services more meaningful in
this area. Her ability to be a sympathe-tic
listener and inject her feelings of
real warmth into a situation is of prime
importance.
The nurse's own feelings may deter-mine
to a great degree the quality of
help she is able to give mentally ill
patients, as well as all other patients.
She probably meets more negative
attitudes regarding her help, but pat-ience
and understanding need to be
employed. She must make her own
decisions as to the techniques she will
try in each individual setting. She
usually can soon recognize the capacity
and readiness of the family and patient
to use her help. The niu"se is accustom-ed
to working with normal, reasonable
people. She does not always get com-plete
cooperation in making other types
of visits. Several visits may be required
in order to accomplish her purpose.
Then, because of the very nature of
8 The Health Bulletin January, 1956
mental illness, should she be discourag-ed
if she meets with even less or
slower response from mental patients
and their families?
More and more educational material
Is being made available to the nurse
through nm-sing and medical journals
to increase her interest and knowledge
in this field. One can hardly pick up a
magazine today which does not con-tain
an article relating to mental
health. More booklets are available in
our health departments which ofifer
help.
In our local department the in-ser-vice
educational meetings, led by Dr.
Roger Howell, of the University of
North Carolina, and Miss Dorothy
Boone, of the State Board of Health,
have been most helpful. They have
greatly stimulated our thinking and in-creased
our imderstanding of mental
and emotional problems.
Also, Dr. Lloyd Thompson and mem-bers
of his staff at Graylyn Hospital
have shared with us their knowledge
and experience, which have been help-ful.
These soiu-ces of help have served to
guide us in seeing how we may be-come
more aware of our need to recog-nize
problems and to make better use
of our resoiu-ces to help meet the needs
of our families.
Some of the resources which we have
used and are cm-rently using are: (1)
the adult mental health clinics, (2) the
child guidance clinic, (3) the special
classes for exceptional children spon-sored
by the city and community school
systems, and (4) the psychological
teams from Graylyn Hospital, who work
in our schools, as was illustrated in the
Blake family situation.
The value of helping families and
patients to seek spiritual guidance can-not
be overlooked. Such help can be
very meaningful to some people espec-ially
to elderly ones and to some who
find experiences such as adjustment to
the death of a loved one very difficult.
The Department of Pastoral Care of
a local hospital is a source of help in
some cases. In others, the family minis-ter
or priest may give such service. The
nm-se may need only to guide the
family in identifying such a need.
The nm'se can help share the respon-sibility
in the community for promot-ing
a mental health education program
by (1) helping minimize the stigma
attached to mental illness, (2) helping
people to recognize early symptoms of
mental illness and the value of early
diagnosis and treatment, (3) helping
our communities to understand better
how to accept the patient back into the
community when hospital treatment
has been used, (4) making available
information regarding educational ma-terials,
such as suitable films and book-lets
and the media of radio and tele-vision,
(5) making known community
agencies which offer help and, (6)
pointing out factors which contribute
to poor mental health.
The factors involved in good physical
health are known by a reasonably large
number of people, but far fewer have
a reasonable knowledge of good mental
health.
The nurse may have the opportunity
to suggest resoiu-ce people in leading
discussions in P. T. A. and civic group
meetings.
Helping in the rehabilitation of the
patient may again become the nxirse's
function. Finding diversions to boost
the interest of the patient, such as
games and crafts, is useful. Constant
encouragement and reassurance of the
patient and his family are needed to
help him adjust to the family and
comjnunity.
To me, the greatest challenge in
public health nursing today is the in-tegration
of all phases of mental health
in our everyday activities.
FEB 16 19S6
OlVlSiON OF
Hfc&LTH l^t^^ '^r^m
MHplOMi
"^ ^^^\ TKis Bulletin -will be scni freey^odnil citizen of iKe 5kt^e upon request I W-Published
monthly at the offlce of the Secietary o£ the Board, Raleigh, N. C
Entered as second-class matter at i>ostofEce at Raleigh, N. C. under Act of August 24, 1912
Vol. 71 FEBRUARY, 1956 No. 2
T
We must not in the Course of
Publick Life expect tmmed-iaU
Approbation and immediate
grateful Acknowledgment ofour
Services.^^But let us persevere
thro' Abuse and even Injury. The
internal Satisfaction of a good
Conscience is always present
and Time will do us Justice
in the Minds of the People
»
even of those at present the
most prejudiced against us«
^^^^^tp ljy2
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Hubert B. Haywood, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
Ben J. Lawrence, M.D Raleigh
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta Hillsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, D.D.S., Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M Jarrett, B.S., Director Sanitary Engineering Division
Fred T. Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departmenta or on
written request.
CONTENTS Page
The Second Year Of American College Of Preventive Medicine 2
Notes and Comment 5
THE SECOND YEAR OF
AMERICAN COLLEGE OF PREVENTIVE MEDICINE
By J. W. R. NORTON, M.D., M.P.H., F.A.C.P.M.*
State Health Officer, Raleigh, N. C.
George Dame, our first President, got lines of our constitution and by-laws.
our infant organization off to a run- Except for basic principles as points of
ning start with his unflagging energy reference we should be a changing,
and pioneering zeal. We shall always moving, dynamic body. As we become
owe much to him for our propitious older we must exert increasingly vigor-beginnings:
for his calling the organi- ous force against becoming a static or
zation meeting in St. Petersburg and reactionary group.
presiding also at the second meeting in ^^ ^^.^ ^^^^^^ grateful to the Ameri-
Chapel Hill, leading in outlmmg our
^^^ ^^^.^^^ Association and to the
objectives and shapmg the broad out- . . _ ,-„ .. ,,j-- •^ American Board of Preventive Medicme
•Presidential address before opening ses- for making our existence possible. For
m^sSrrNoVember^ef 1955^'
^''"'^' ^'^^' their continuing helpful assistance and
February, 1956 The Health Bulletin
for that of the American Public Health
Association, we shall ever be apprecia-tive.
We shall make fewer mistakes of
omission and commission if we proceed
"not in entire forgetfulness" of our
humble beginnings and of those sup-porting
our first awkward steps. We
can and must earn the respect of the
older specialist board groups. Those
here tonight, and those who could not
attend, have a strategic opportunity to
shape and to steer our destiny now
while we are young and more respon-sive
to such individual efforts. We have
the responsibility to see constructive
guidance provided toward growth in
strength and influence—"in wisdom, in
stature and in favor." We can begin by
simply promoting growth in numbers
through encouraging qualified persons
to take the Board examination, join
our College and work with us in wield-ing
increasingly constructive support
for preventive medicine. The deadline
for becoming charter members con-tinues
through the present calendar
year.
We must grow in quality as well as
size. Sound work deserves accurate and
prompt recording and documentation.
Reporting and discussion among our
able group will identify, clarify and
define our primary problems and op-portunities.
Stimulation toward logical
next steps in careful evaluation and
vigorous progress should follow. Our
group is in a peculiarly good position
to cut down on the lag between acquisi-tion
and the general utilization of pre-ventive
medicine information. Our per-sonal
as well as our professional con-duct
can build credit and good will. As
collectively and individually we use our
almost limitless opportunities for pro-motion
of preventive medicine the
initials of our College will become a
trademark of prestige and respect. Let
us not, however, become impatient for
recognition nor weary in well-doing.
Modesty, patience, dependability are
becoming to any age and especially to
youth. While recognizing that haste
causes grave mistakes we must retain
our enthusiasm to move forward.
Our purposes, ideals and services will
grow. Think of the simple beginnings
of any of our great and good organiza-tions.
In many respects their growth
has been comparable to the lives of our
most useful men and women. We should
not demand nor even expect "the dis-tant
scene", but with each well-placed
forward step the mists will clear and
our horizons should enlarge.
Each of us has, or has had, the
question: "With so many professional
organizations already, is there need for
the American College of Preventive
Medicine?" Our answers will vary.
What can this body accomplish that
could not be as well, or better, done by
one longer in operation? I shall men-tion
a few and invite each of you to jot
down and hand or mail to me your
own thoughts, and I shall see that they
are given consideration in planning for
the future.
1. Neither preventive medicine nor
our component parts—public health,
aviation medicine and occupational
medicine—has organized and concerted
promotion and support. We have power-ful
(and sometimes misguided) efforts
for categorical entities, such as poliom-yelitis,
cancer, tuberculosis or venereal
disease. There is glamor and emotional
appeal in these narrow fields—in treat-ment,
in the tangible brick and mortar
of buildings, in even partial salvage of
those crippled by injury or disease and
hence in need of definitive treatment
or rehabilitation services. Our group
should believe more strongly than any
other in that ounce of prevention and
its fundamental economy. Individually
and collectively, we should have a con-vincing
message.
2. There are increasing numbers of
medical graduates in research, teach-ing,
group practice and in civilian and
armed forces government service. A few
of these in their confusion and lack of
appreciation of the best in our tradi-tional
concepts tend to infringe upon
the field of private practice. The great
majority of physicians are in individual
fee-for-service practice, and a few of
these are becoming increasingly fear-ful
and impatient with one and all not
in their particular category. Our na-
The Health Bulletin February, 1956
tional good fortune in health and medi-cal
care is not due entirely to any
single group (as some claim) but to
united health and medical efforts and
owe generally high living standard. If
our new organization can work effec-tually
toward preserving individual
freedom and dignity by reorientation of
these disrupting elements within the
medical profession itself and thereby
serve to unify and harmonize all medi-cal
forces against ill health with its
physical and mental disablement and
premature death, and not against each
other, we shall have earned our keep.
3. The component gi'oups of the Col-lege
can serve as an aid and stimulus
to each other as we work more closely.
The story we shall hear tomorrow
morning of the Cornell Automobile
Crash Injury Study provides a clear
example of constructive work started
by aviation medicine and followed
through by public health. Both of these
groups have much to learn from occu-pational
medicine. Our College brings
the leading thinkers and workers of the
three component groups together for
catalytic action.
4. The most important single step in
preventive medicine is the development
and strengthening of local health de-partments
to serve all our people—and
I do not mean branches of the state
health departments. We need more
local autonomy and pride, with a de-sire
to support, financially as well as
otherwise, local preventive services.
Small local health departments can be
operated economically only on a
generalized basis. Our categorical
groups do not realize fully that their
specialties can best be promoted
through this locally supported gen-eralized
setup. We have no clear and
influential voice in behalf of this gen-eralized
approach. Oui- College could
have no more vital vision and goal than
sound decentralized local health de-partments,
employing generalized as
well as specialized workers, providing
an outlet for all categorical or specializ-ed
interests and serving the entire
population. The continuing joint re-sponsibility
for our nation's health
—
local, state and federal—must be recog-nized,
and the College should help in
developing backing of ovir appropriat-ing
bodies so that neither of the three
shall shirk its duty to the other two
and to all our people.
5. Our College may well take a lead-ing
part in the orderly shift of em-phasis
from communicable diseases to
degenerative diseases and special prob-lems
of the aging population, mental
disorders, accidents (and we should
have a more fitting name for this
group), stream and air pollution, nutri-tion,
rehabilitation of the handicapped,
etc. We must keep firm control on the
old while taking in hand the new. Our
knowledge of viruses and mental dis-orders
falls about where we stood in
relation to bacteria a half century or
more ago. Present and rapidly accumu-lating
knowledge and experience make
progress at a livelier pace possible, and
the College can assure its continuing
realization.
The College of Preventive Medicine
is made up of the group best fitted to
point the way and clear the path in the
five areas to which I have so briefiy
referred. You will each think of others
(and so have I, but I picked just these
to mention). Anyway, we have plenty
to challenge our swaddling infant, and
after we learn to crawl and walk we
can move on to run and jump—and
then to really serious and mature
thinking and work.
Finally, a word on our immediate
problems. Our business sessions tonight
and tomorrow enable us to develop our
organizational pattern still further and
better through improvements in our
Constitution and By-Laws. I recom-mend
official incorporation and the
combining of the ofiBces of Secretary
and Treasurer, and we should allocate
a reasonable fund for ofl&ce expenses.
We should decentralize as much as
possible to place the main responsibil-ity
with the State Academies—and in
some states possibly still further to
local units. Our oflBcers should always
be active exponents and supporters of
preventive medicine and not just figure-heads.
Even tho now we see thru the
veil darkly our pioneering spirits re-spond
eagerly as the horizon beckons.
February, 1956 The Health Bulletin
NOTES AND COMMENT
By THE EDITOR
NORTH CAROLINA HOSPITAL
FOOD SERVICE INSTITUTE
The fourth annual Hospital Food
Service Institute will be held at North
Carolina State College, Raleigh, June
13, 14, 15, 1956. This Institute, which is
sponsored by the North Carolina Hos-pital
Association, Dietetic Association
and State Board of Health, is planned
for food service managers in small hos-pitals
having 20 to 100 beds. Hospital
administrators are also invited to at-tend.
Announcements will be sent to hos-pitals
in the above category in the near
futm"e. Each hospital is ui-ged to send
representatives to the Institute. Regis-tration
will be limited to 55, so anyone
wishing to attend should send in the
pre-registration blanks immediately
upon recipts.
Further information can be secured
from the Nutrition Section, State Board
of Health.
ACCENT ON HEALTH
(Municipal Reference Library NOTES,
Vol. XXXIII, November, 1955, No. 9)
"Public health has to do with per-sons
of every rank, of both sexes, of
every age. It takes cognizance of the
places and houses in which they live; it
follows the child to school, the laborer
and artisan into the field, the mine, the
factory, the workshop; the sick man
into the hospital; the pauper into the
work house; the lunatic to the asylum;
the thief to the prison. It is with the
sailor in his ship, the soldier in his
barrack; and it accompanies the emi-grant
to his new home beyond the seas.
To all of these it makes application of
a knowledge remarkable for its amoimt,
and the great variety of sources whence
it is derived. To physiology and medi-cine
it is indebted for what it knows
of health and disease; it levies large
contributions on chemistry, geology,
and meteorology; it cooperates with the
architect and engineer; its work com-mends
itself to the moralist and di-vine."—
From Public Health, a series of
lectures by Dr. William A. Guy,
London, 1874.
The above quotation was called to
our attention by one of the good doctors
in the Department of Health with the
additional information that Dr. Guy,
who was practising in England a cen-tury
ago, also found time to lecture
and write in the fields of physiology,
legal medicine, hygiene, social science,
medical statistics, chemistry, and mic-roscopy.
It's a very large claim he has
staked out for public health, but he
must have had some foreknowledge
that it would be thoroughly worked. A
pity he couldn't have lived on into this
century
!
DOCTOR PREFERS STEAM KETTLE
TO NEWER HUMIDIFIER
The good old steam kettle works bet-ter
than a mechanical humidifier for
treating a childhood respiratory dis-order,
a Haifa, Israel, physician said
recently.
Dr. Abraham Friedman said that the
steam kettle is better because it can
produce more moisture than a cold-air
mechanical humidifier, the now gen-erally
accepted apparatus. Moist air
helps prevent the blocking of breathing
passages which may occur in an acute
infiammatory disease of the larjmx,
trachea, and bronchi.
He explained that in breathing, the
air enters the respiratory tract at room
temperature and humidity. On its way
down the air absorbs moisture from the
membrane lining the passages. It final-ly
is exhaled at body temperature and
saturated with water. The difference in
temperatures and humidities between
the air inhaled and exhaled results in
a continuous loss of water from the
respiratory tract.
In acute respii'atory disease, the loss
is speeded up and the breathing pas-sages
eventually may be blocked by the
formation of a dry crust on the mem-
6 The Health Bulletin February, 1956
branes. The drier the inhaled air, the
more water it absorbs from the mem-branes,
thus increasing their "drying
out."
To prevent obstruction, the air
breathed in must be as moist as the air
breathed out. This means that the
temperature and humidity of the air
inhaled should be approximately equal
to the temperature and humidity of
the air exhaled.
Since there is a ceiling on the amount
of water air will hold at a specific
temperature, the air temperature must
be raised to increase water content.
The mechanical humidifier may raise
water content, but the low-temperature
air cannot hold as much water as high
temperature air would, he said, adding
that a steam kettle accomplishes both
things.
While recormnending the steam ket-tle
method, Dr. Friedman warned that
necessary precautions must be taken
against the hazards of a bum and the
develoment of a high fever in the child.
Dr. Friedman, of the department of
pediatrics of Ramham Government
Hospital, made his report in the Arch-ives
of Otolaryngology, published by
the American Medical Association.
COMMITTEE OUTLINES PROGRAM
FOR POISON CONTROL
The American Medical Association's
Committee on Toxicology outlined four
methods for combating the perennial
problem of accidental childhood poison-ings.
The methods include education, more
stringent laws, establishment of poison
centers, and greater efforts by local
physicians. They were discussed in a
report prepared for the committee by
Dr. Jay M. Arena, Durham, N. C, and
published in the Journal of the Ameri-can
Medical Association.
Bernard E. Conley, secretary of the
committee, said ". . . the curiosity of
children coupled with the casualness
with which many parents handle and
store drugs and chemicals are predis-posing
factors to most unintentional
poisonings."
The "alarming feature" of the prob-lem
is the regularity with which various
household agents and drugs are swal-lowed
by children, the report said.
Leading causes are drugs, especially
aspirin and barbiturates, petroleum
products, lead, corrosive agents such as
lye, and arsenic.
Of approximately 14,000 accidental
deaths that occur each year among
children from 1 to 14 years, almost
1,500 are reported as being caused by
accidental poisoning, but this figure is
"far from correct" for many cases are
never recorded, the report said.
Cnildhood deaths from poisoning
occur disproportionately often in 12
southern states—Alabama, Arkansas,
Florida, Georgia, Louisiana, Mississippi,
North and South Carolina, Oklahoma,
Tennessee, Texas, and Virginia, the re-port
said.
For the barbiturates and aspirin there
is little regional difference, but for
corrosives and arsenic the rate in these
southern states is six times that for the
rest of the country. The rate for
petroleum products, principally kero-sene,
is four times as high.
"Quite apparent to everyone" is the
need for educating laymen and parents
to the dangers of household agents, but
many physicians also are unaware and
must be educated, the report said.
Manufacturers must be made aware of
the seriousness of the problem and of
their responsibilities. They should con-sider
the use of distinctive safety con-tainers
and better labeling with warn-ing
statements and when necessary
uniformly standarized doses for drugs.
While the present federal laws are
useful as far as they go, they are far
from adequate, the report said. Laws
regulating the sale of household articles
not covered by existing laws must be
considered. Physicians and lay groups
should work for state laws to strength-en
federal ones and to bring about
correction of their special state prob-lems.
The report suggested that the sale
of kerosene be restricted except in a
special type of container, which would
also carry a label warning of its
poisonousness and inflammability.
Poison centers should be set up to
collect and distribute information on
February, 1956 The Health Bulletin
the type, frequency, treatment, and
preventive measures for poisonings.
Another step forward would be a
concentrated effort by every physician
to educate parents to the hazards of
household agents. This could be done
by pointing out corrective measures
while making house calls, distributing
safety literature to mothers, using bul-letin
board displays in the office, en-couraging
community programs to
study the problem, and giving infor-mation
to radio stations, newspapers,
and magazines.
Much can be accomplished by asking
pharmacists to put labels such as "Keep
out of the hands of children" on all
dangerous drugs and agents, the report
said.
Dr. Arena is associate professor of
pediatrics at Duke University and di-rector
of the Poison Control Center of
Durhar?..
"HEAD INJURY EPIDEMIC"
COULD BE PREVENTED
The only cure for the "head injury
epidemic" now sweeping the country is
prevention through safer automobile
construction, a California neurosurgeon
has said.
Head and neck injuries account for
nearly 70 per cent of all auto crash
deaths, Dr. C. Hunter Shelden, Pasa-dena,
said in the Journal of the Ameri-can
Medical Association. In spite of the
"most concerted efforts" of neurosur-geons,
the severe head injury is fatal,
for once the brain is injured beyond a
certain degree, there can be no re-covery,
he said.
Last year there were 5,200,000 report-ed
auto accidents, 1,500,000 resultant
injuries, 100,000 persons totally disabled,
and 38,000 deaths—"rather lethal statis-tics
to refer to a so-called pleasure
car," Dr. Shelden said.
Pressure is developing that will bring
about safety improvements, but so far
there has been "much smoke but no
fire," he said. Changes must be made
at once and not in a piecemeal man-ner.
"Such a delaying action may be a
satisfactory policy in business, but not
in a matter of health and public safety.
Translated into medicine, it would be
comparable to witholding known meth-ods
of lifesaving value," he said.
Engineers have supplied valuable
safety ideas, but they have had only
limited use, because the automobile in-dustry
"apparently is governed entirely
by the cost accounting division," he
said. No new idea can be adopted un-less
it reduces present costs or promises
better sales.
However, safety is the one feature
that the public will accept if given the
opportunity, without the need of
propaganda and expensive advertising,
he said.
Because no company can afford to
imdertake an immediate and complete
safety program. Dr. Selden suggested
that a national group be set up to
regulate and approve automobile safety,
allowing industry to pool safety ideas,
standardize construction methods, and
avoid competition.
Dr. Shelden outlined some suggestions
for improved auto safety, pointing out
that if a medical research group can
devise safer construction methods
engineers could come up with even bet-ter
ones.
Of particular concern in preventing
head and neck injuries is seat con-struction,
which Dr. Shelden called "a
disgrace to the combined engineering
staffs of the automobUe industry."
Seats are designed for comfort and not
for safety. The fixed portion of the
seat is fastened to the frame only by
four small bolts, which allow frequent
seat failures. Seat cushions are not
securely fastened, are easily torn loose
and tossed about in a crash, and can
cause fatal injuries.
Poor seat design accotmts for thous-ands
of "whiplash injuries," which
occur when the car is struck from the
rear. With the impact, the head is
thrown backwards. Since the seat back
is low, the top of the seat serves as a
fulcrum over which the neck is snap-ped.
Whiplash injuries are the most
disabling of all nonfatal auto injuries,
he said.
Dr. Selden suggested that a small
elevated portion of the seat be placed
8 The Health Bulletin February, 1956
directly behind the head—not high
enough to support the head while driv-ing
but high enough to give the head
support if the neck is suddenly extend-ed.
He also said a method that would
rigidly attach both doors to the out-side
edges of the front seat backs is
needed. This would hold the doors
tightly shut and prevent the front seat
backs from flying forward. A better
locking method is necessary to keep
passengers from being thrown from the
car. Between 25 and 35 per cent of all
deaths occur in this manner.
There has been some improvement in
interior projections, but dashboards still
have dangerous knobs and buttons that
can "easily produce" serious depressed
skull fractures in a crash, he said. He
also suggested the addition of a roll
bar to prevent the crushing of the pas-senger
compartment if the car rolls
over.
He said current safety belts with two
straps are inconvenient, because the
free ends when not in use lie across the
seat, fall out the door or on the floor.
In order to fasten the belt, both
hands must be taken from the wheel
and attention turned from the road. A
belt that rolls up when not in use and
can be fastened with one hand would
improve the situation. Until improved
designs are available, the public is not
going to take full advantage of safety
belts, he said.
"Eventually a method must be de-veloped
whereby the passenger is auto-matically
and instantaneously restrain-ed
during a crash," he said.
COMMITTEE TELLS DANGERS
OF INSECTICIDE
The Committee on Pesticides of the
American Medical Association has
warned of the danger of poisoning by
chlordane, an agricultural and house-hold
insecticide.
Deaths following chlordane poisoning
were reported in the Journal of the
A.M.A. as part of a discussion of the
possible hazards of using the insecti-cide.
Poisoning may be caused by repeated
skin contact, breathing of the fumes or
accidentally swallowing the chemical.
Chlordane appears to be absorbed more
rapidly than similar insecticides, the
report said.
Chlordane is effective in controlling
such pests as grasshoppers, ants, flies,
mosquitoes, and roaches. It is avail-able
in oil solutions, emulsion concen-trates,
dusts, paints, and waxes.
The insecticide should not be used on
food crops with exposed edible parts or
on crops fed to animals, because the
chemical can be retained in the food
and in milk, eggs, and meat, the com-mittee
said.
Its use in the home should be limited
to spot treatment around kitchen base-boards,
doors, and windows. Care should
be taken to avoid areas frequently con-tacted
by children. It is not approved
for over- all interior use, because slow
liberation of fumes, especially in closed
heated rooms, is dangerous.
Because chlordane is readily absorb-ed
through the skin, the committee
cautioned against its use in insecticidal
waxes and polishes which touch the
skin.
Symptoms of chlordane poisoning in-clude
irritability, labored breathing,
muscle tremors, convulsions, and deep
depression. Others are nausea, vomit-ing,
diarrhea, abdominal pain, blurred
vision, cough, confusion, and delirium.
The onset of symptoms is influenced
by the means of absorption. Acute signs
usually appear within 45 minutes after
swallowing the poison. Death may
occur within 24 hours and is frequent
between the 48th and 96th hoiu:, the
report said.
The treatment consists of removal of
the poison from the skin or stomach,
followed by a salty purge and adminis-tration
of sedatives. In case of skin
contact, the contaminated area should
be washed immediately with soap and
water. If chlordane is swallowed, wash-ing
of the stomach, followed by ad-ministration
of epsom salts or other
salty cathartics is recommended. Since
milk, oil purgatives, and other fatty or
oily substances speed absorption of the
poison, they should be avoided.
u
WJJ^^'i^^ ^^
F£3 16 1936
DiV5iON OF
jjEALTH^iRS LIBRARY
l(i®lllb®il
I TKisBuUefin. will be sehi hezfo dnij ciiizen of fKe Skite upon request i
Published monthly at the office of the Secretary of the Board, Raleigh, N. C.
Entered as second-class matter at /"ostoffice at Raleigh, N. C. under Act of August 24, 1912
Vol. 71 MARCH, 1956 No. 3
STOKES COUNTY HEALTH CENTER
Danbury, North Carolina
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Ben J. Lawrence, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta Hillsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
Lenox D. Baker, M.D. Durham
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, D.D.S. , Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M. Jarrejt, B.S.. Director Sanitary Engineering Division
Fred T. Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departments or on
written request.
CONTENTS Page
Life and Death In 1955 2
Notes and Comment 5
LIFE AND DEATH IN 1955
BY WILLIAM H. RICHARDSON
State Board of Health
Raleigh, North Carolina
For many years now, the State Board Statistics, as such, mean very little
of Health has maintained an increas- to the average person, but, when prop-ingly
accurate record of births and erly interpreted, they can furnish a
deaths in North Carolina. All births are world of interesting and helpful infor-reportable,
as well as all deaths. There- mation. The mere fact that a given
fore, under the present system, the number of people came into being dur-
State Board of Health is able to collect ing a certain year, or that a certain
and to give out information as to the number died, means very little. There
cause of each death reported. Such rec- is more human interest attached to
ords as those just referred to are known deaths from various causes than to
as vital statistics—the "bookkeeping of births. The method by which people are
life and death." born into the world has never changed.
March, 1956 The Health Bulletin
so far as we know, but the causes of
death have varied through the years.
Some diseases which formerly took a
heavy toll of life each year now are
practically extinct. We shall get to that
later.
The State Board of Health issues a
month-by-month report of births, total
deaths and deaths from selected causes.
Each of these reports is cumulative.
The most interesting, however, is that
which appears when all preliminary
figures for December have been receiv-ed.
This report, which is issued during
the first part of each year for the
previous year, is provisional and is sub-ject
to changes imtil all reports have
been received, compiled, and verified.
Some time ago the Public Health Sta-tistics
Section of the State Health De-partment
issued its provisional figures
for 1955, showing the results of the
"bookkeeping of life and death" in this
State during the past calendar year.
At first glance, this report is just so
many figures. Analyzed, however, it
shows a progressive pictui-e of the
health of our people over a period of
years. Published reports carry a sum-mary
of all births, including and since
1914, and of deaths from selected causes
including and since 1916.
New High Birth Total
Let us now pinpoint the provisional
figures for 1955 and make some inter-esting
comparisons, as we proceed. Last
year North Carolina's total number of
live births reached an all-time high,
nath 116,206 reported up to the time the
provisional figures were compiled. Dur-ing
the previous year, that is 1954, the
total was 115,889. We now have a popu-lation
of more than four and a quarter
million people.
In 1914, when our population was
estimated to be 2,421,191, the nimiber of
live births reported to the State Board
of Health was 71,931. Just what the
actual total was we will, perhaps, never
know. That was the first year for which
figures were published, and the report-ing
system was very inadequate, as
compared to the present time.
As previously stated, we all enter this
world through one door, namely natui-al
birth; but, although the wall of parti-tion
between this life and the next is
death, there are many doors through
which people pass into the Great Be-yond.
Through the miracles of medical
science, many of these doors which
formerly beckoned thousands to pass
thi'ough their portals have been all but
closed, certainly in the United States.
We might take typhoid fever as one ex-ample
of this. The 1955 provisional re-port
does not even mention typhoid
fever, because there was only one death
from that cause in 1955, while in 1916,
702 typhoid and paratjTDhoid deaths
were reported to the North Carolina
State Board of Health. During that
same year, malaria deaths reported
totaled 337, while none occured in our
State last year. Both typhoid and ma-laria
have been practically eliminated
through immunization, sanitation and
drainage; but, if we should lower our
guard, these killers would seize the op-portunity
to strike again.
Before taking up the subject of other
deaths from selected causes, let us
pause for a moment and consider two
comparative totals. In 1914, when our
population was less than two and one
half million, 29,044 deaths from all
causes, were reported to the State
Board of Health. Last year, with a pop-ulation
of more than four and a quarter
million, only 32,469 deaths from all
causes, were reported. To tell the whole
story would require much more time
and space than are available.
Certain Notable Declines
Before pointing up this discussion
with some extremely significant facts,
suppose we review, briefly, the decline
in deaths from certain diseases which
have been brought under control
through the application of the prin-ciples
of preventive medicine.
We shall begin with the cradle and
tell what it furnished the grave. In
1914, when there were only 71,931 live
births reported in North Carolina, there
were 6,497 deaths reported among in-fants
under a year old. Compared with
that, there were only 3,577 such deaths
The Health Bulletin March, 1956
reported last year, when the total num-ber
of live births was 116,206.
Before leaving this field, let us note
one other extremely interesting com-parison.
In 1914, with the number of
live bu'ths previously referred to, ma-ternal
deaths numbered 524, that is.
there were that many deaths resulting
from pregnancy and childbirth. Last
year, when there were more than 116.-
000 live births reported in North Caro-lina,
only 100 mothers laid down their
lives. We shall not go into the causes
for this phenomenal decline, the broad
reason for which has been the more
affective application of the principles
of preventive medicine.
Compulsory Immunization
Nearly two decades ago the legislature
of North Carolina passed a law requir-ing
the immunization of children
against diphtheria during the first year
of life. How has this worked? We still
are thinking in terms of preventive
medicine. In 1916, when our babies and
small children were wide open to at-tack
by this disease, 410 died. In com-parison
with this, there were only four
diphtheria deaths reported in North
Carolina in 1955. During 1939, when the
immunization law v;as passed, there
were 164 deaths among our children,
resulting from diphtheria. The decline
since that date has been steady, with
only one flare-up. That was in 1945.
Despite the fact that this law may not
have been enforced as it should have,
we have seen the results previously re-ferred
to. It would seem therefore, that
enforcement is becoming more uni-versal.
Whooping cough is another childhood
disease which is being brought under
control by preventive medicine. Com-pulsory
immunization against this dis-ease
is required by a law passed in
1945. During that year, there were 97
whooping cough deaths reported in
North Carolina. By 1953 the total had
been reduced to seven, while only ten
whooping cough deaths were reported
in 1954; but, in 1955, for some reason,
there were 32. Whooping cough, as all
of us know, occurs in cycles. Even be-fore
the immunization law was passed,
it had become preventable, and many
parents were resorting to immimization
as a means of protecting their children.
It might be well to state, in this con-nection,
that if whooping cough had not
been known to be preventable, the State
Board of Health would never have
sponsored a law requiring immuniza-tion.
Public health never considers an
experiment. Any preventive agent must
have proved itself before it is either
adopted or advocated by those who are
charged with the mass protection of
our people.
Another disease that has been suc-cessfully
attacked through the use of
new drugs in pneumonia. There was a
time when all a patient and his attend-ing
physician could do was to await
"the crisis" and, when that was suc-cessfully
passed, to administer, perhaps,
some stimulant and pray that the pa-tient
was on the road to recovery.
It is not customary to mention "rem-edies"
in a discussion of this nature,
but we do know that, through the use
of certain drugs which can be prescrib-ed
only by physicians, pneumonia in-fection
often can be cleared up within
a comparatively short time. During
1955 influenza and the various types of
pneumonia resulted in 1,203 deaths in
North Carolina. That was a large num-ber,
to be sure. But what about what
many call "the good old days?" In 1916
there were 2,517 pneumonia deaths re-ported
to the North Carolina State
Board of Health. In 1918, the year of
our biggest flu epidemic, there were
4,210. As late as 1934 pneumonia deaths
totaled 3,173. Since the discovery of cer-tain
antibiotics, deaths have been on
the decline during most years. However,
statistics show that this disease is not
entirely whipped, by a long way.
In 1955 there were only 11 polio
deaths reported in North Carolina,
compared with 23 the previous year.
The largest number ever reported was
143 in 1948, when we had our biggest
epidemic. While polio is a dreadful dis-ease
and its crippling effects are very
distressing, in many instances, it is a
small killer compared with accidents
March, 1956 The Health Bulletin
and some of the others that can be
prevented.
Some Significant Facts
Let us now bring this discussion to a
climax with some statistics that are
more than just so many figures. More
people today are living to a "ripe old
age" than ever before in our history.
A hundred years ago the average span
of life was around 40 years. Today it
has about reached the Biblical standard
of "three score years and ten." There
are more old people among us today
than ever before and more who have
passed the dangers of infancy, child-hood
and middle life. These people are
subject to causes of death which are
not so common among young people.
These are commonly called the degen-erative
diseases. Without undertaking
to explain what is meant by that term,
let us consider a few startling figures.
Early in this discussion it was point-ed
out that the total number of deaths
occurring in North Carolina last year,
from all causes, was 32,469. Of this
number, 11,245 died as the direct result
of heart disease; 4,440 were victims of
apoplexy, and 3,939 died of cancer.
Deaths from each of these diseases
continue to climb with the passing
years and with the increasingly large
number of people who live to reach old
age. These three causes last year ac-counted
for 19,624 deaths, out of a
total of 32,469. None of the three has
yet been classified as preventable. On
the other hand, they present a gigantic
challenge to practitioners of the med-ical
profession, both curative and pre-ventive.
That is why public health con-siders
the degenerative disease in the
category of those human ailments
which must be studied with a view to
bringing them within the range of pre-vention.
Physicians have found that persons
suffering from any of these diseases
need not consider themselves in a
hopeless plight. Those with diseases of
the heart and circulatory system can
be taught ways and means of living
with the conditions luider which they
suffer, if they will consult their family
physicians while there is yet time. Some
cases of cancer can also be cured, if
discovered in time for proper treatment.
And so we bring to a close a discus-sion
of life and death in North Caro-lina
for 1955.
NOTES AND COMMENT
BY THE EDITOR
PARENT-CHILD CONFLICTS
CAUSE BREATH-HOLDING
Frequent severe spells of breath-hold-ing
by a small chUd are a sign of "pro-found
insecurity" often resulting from
conflict with his parents, two pediatri-cians
said recently.
Drs. Alanson Hinman, Winston-
Salem, N. C, and Lloyd B. Dickey, San
Francisco, said in the American Journal
of Diseases of Children, pubUshed by
the American Medical Association, that
breath-holding is an early form of
temper tantrum—a primitive expression
of anger or frustration.
A child may become frustrated be-cause
he is unable to cope with the
world or because he feels insecure with
his parents. In his helplessness, having
no means of adequate expression, he
reacts with rage "so overwhelming"
that he loses control over himself and
goes into a spell, they said.
Treatment must be directed toward
a solution of the family conflict and
helping the parents understand the
emotional basis of the spells, the
physicians said. The older methods-plunging
the child into cold water or
ignoring him during a spell or point-ing
out to him that similar behavior
will be met with "harsh, if not painful,
measures"—certainly should be avoid-ed,
they said.
6 The Health Bulletin March, 1956
The little child's only way of pro-testing
against a frustrating world is
by crying and throwing himself around.
Anything approaching the same kind
of behavior on the part of adults will
aggravate the situation, they said.
"Every effort should be directed to-ward
removing the soiu'ces of conflict,
such as coercion in eating, overly strict
or too early bowel and bladder train-ing,
pressure in the matter of naps and
bedtime, and other premature and ex-cessive
demands on the child," they
said.
The parent should be reassured that
the child can receive no physical or
mental damage from the spells them-selves.
They should be helped to under-stand
the difference between discipline
and pimishment and to establish a
"tolerant and consistent disciplinary
regime," the authors said. In some cases
the parents may need help in adjusting
their own emotional problems.
Spells occur most frequently in the
last half of the first year and during
the second year of life. Tliey usually
are precipitated by injury or frustration
and the resulting anger, the physicians
said.
The sequence of events in a spell is:
crying, a long - sustained expiratory
"cry" without succeeding inhalation of
air, a slight blueness or paleness after
the previous flushing of the face, stif-fening
of the limbs, loss of conscious-ness,
relaxation, inhalation, and recov-erj'.
Some children are weak or ex-hausted
after a spell, but most seem
entirely normal after breathing is re-established,
they said.
Breath-holding spells are sometimes
confused with epileptic seizures and
other lesser-known disorders. Epileptic
attacks and breath-holding speUs can
be distinguished because of the differ-ence
in "crys." Convulsions in breath-holding,
"which are rare anyway," are
mild compared to the "dramatic" ones
of epilepsy, and the epileptic seizures
usually do not follow some specific
event such as a fall or frustration.
They said that if any "real doubt"
exists, a thorough medical study should
be undertaken.
The physicians outlined 11 cases
among children ranging in age from
one year to five years, seven months.
There was only one over two and a
half, and the average age, excluding
the oldest, was approximately one year,
nine months.
The age at onset of the spells ranged
from three to 24 months, the average
being a little over 10 months. The fre-quency
of spells ranged from eight
spells in a year to as many as 10 or
15 a day.
In several cases, strained relation-ships
within the family were obvious.
In four cases, there were conflicts about
feeding, and in three, about toilet
training. In three families there was
frustration from relatives living in the
family, and in two there was marital
friction. In at least two, the parents
seemed to be overly demanding and
strict. There was a family history of
breath-holding spells in four.
In six of the children the spells ceas-ed
in a few months. One was much
better two years later, and one, accord-ing
to the family doctor, became an
epileptic. There was no follow-up on
three of the children.
NEWBORN INFANT DEVELOPS
OWN POLIO IMMUNITY
Infants born while their mothers
have acute polio may be infected with-out
showing outward signs, two Mary-land
physicians have said.
In the Journal of the American Med-ical
Association, they told of a new-born
baby who acquired polio from his
mother before or during birth, develop-ed
his own immunity to the disease,
and never showed signs of infection.
As far as the doctors know, this is
the first reported case of infection
without outward signs in an infant bom
during the mother's acute phase of
polio. Further investigation, though,
may show this sort of infection to be
common, they said.
The infant, born about two weeks
after the mother developed an acute
case of polio, was "normal" and remain-ed
"well" at all times. However, lab-oratory
examination of rectal swabe
March. 1956 The Health Bulletin
showed him to be infected with the
same polio virus as his mother was.
Examination of his blood serum re-vealed
many antibodies (agents de-veloped
by the body to combat foreign
substances such as viruses). At three
months, the infant's antibody level was
approximately the same as his mother's.
He apparently manufactured his own
antibodies, since the cord fluid at birth
contained very few and he was never
breast fed, they said. This indicates
that the mechanism for manufacturing
antibodies was well developed even in
the first months of life, they said.
The infant probably acquired the in-fection
before birth, since the placenta
contained viruses. However, he may
have been contaminated with the
mother's virus during delivery, they
said.
The report was made by Drs. Alexis
Shelokov and Karl Habel from the lab-oratory
of infectious diseases. National
Microbiological Institute, National In-stitutes
of Health, Bethesda, Md.
SORE THROAT TREATMENT
CHANGES OVER YEARS
A man with a sore throat today is
better off than George Washington was
when he had one in 1799.
During his fatal illness, which began
with a sore throat, in December of that
year, Washington was treated with "the
best" eighteenth century methods
—
"bleeding," the application of "blisters"
to the neck, gargles, inhalations, cath-artics,
and immersion of his feet in hot
water. Dr. Noah D. Pabricant, Chicago
otolaryngologist, said.
Now treatment for sore throats in-cludes
antibiotics and sulfonamides for
severe cases and the "time-tried" meth-ods
of complete bed rest, adequate
amoimts of fluids, salicylates for the
control of fever and irrigation of the
throat with warm salt water for mild
cases.
In Washington's day, the diagnostic
method of chest thumping and listen-ing
was unknown and no one thought
to examine his throat. His illness was
diagnosed as "quinsy" (an abcess near
the tonsils) and later as "cyanche trac-healis,"
an indefinite medical term then
in vogue for a severe sore throat that
involved the vocal cords.
Although the exact diagnosis of his
illness is a matter of dispute, it seems
likely that a strain of streptococci or-ganisms
was responsible, Dr. Fabricant
said in Today's Health, published by
the American Medical Association.
In past years complications from
"strep sore throats" were common, but
now antibiotics and sulfonamides are
effective weapons against the terror of
streptococcus infection, he said. "Strep
throats" usually start suddenly, with
chills and high fever. Some patients
develop a skin rash, so sometimes it is
difficult to distinguish this disease from
scarlet fever.
The "common, garden-variety" sore
throat usually results from irritation
or infection of the back wall of the
throat (pharyngitis) or of the tonsils
(tonsillitis), he said.
Acute pharjTigitis is caused by many
different types of microorganisms and
viruses. The symptoms include sensa-tions
of burning and scratchiness, a
constant desire to clear the throat,
painful swallowing, fever, headaches,
loss of appetite and a dry, harsh cough.
In the acute stages, pharyngitis grad-ually
wears itself out, but bed rest, ade-quate
amoimts of fluids and salicylates
are helpful. If the fever is or remains
high, use of antibiotics and sulfona-mides
to prevent complications may be
necessary, he said.
While gargling is popular, there is
considerable doubt as to its value. Dr.
Fabricant said. Experiments have
shown that fluids fail to reach either
the back of the throat or the tonsils,
because the gargling causes the back
of the tongue to meet the soft palate,
closing off the back part of the throat.
However, it is possible to irrigate that
part of the throat with a syringe.
Various studies have shown that ordi-nary
mouth washes "can do no more
than wash," he said. They are in con-tact
with the infected area for too
short a time to kill the bacteria and
viruses.
As in acute pharyngitis, antibiotics
8 The Health Bulletin March, 1956
and sulfonamides have taken the
"sting" out of tonsillitis. Bed rest, fluids,
easily swallowed foods and salicylates
also help give relief.
INFECTIOUS DISEASES STILL
TAKE "IMMENSE TOLL"
"Top priority" in the U.S. health
programs must be given to communi-cable
diseases, because they most fre-quently
attack "the young and vigorous
... on whom the present and future
productive power of the nation de-pends,"
a U.S. Public Health Service
official said recently.
While "major killers of a half cen-tury
ago" largely have been controlled,
other communicable diseases still take
an "immense toll" in death and dis-ability
among citizens of the U.S., Dr.
Theodore J. Bauer, chief of the U.S.
Communicable Disease Center, Atlanta,
Ga., said in the Journal of the Amer-ican
Medical Association.
One of every 10 deaths is caused by
a communicable disease. The situation
is "far more serious" in the age group
under 35 years, where the ratio is 1 to
4. In the older group it is 1 to 12. In
addition the diseases cause the majority
of absences from school and work. They
also may lead to future disorders of the
heart, liver, kidney, nervous system and
other organs.
Public health workers aim toward the
control of all communicable diseases.
Dr. Bauer said. Control measures for
diseases of today must be developed
and research into diseases of obscure
origin must continue.
If those "spectacular and dreadful"
diseases of the past, such as yellow
fever, typhus and smallpox, are to re-main
in check, constant watchfulness
and effective use of available control
measures are necessary, he said.
"Perhaps of greatest concern at the
moment" are the "ultramicroscopic"
viruses. Dr. Bauer said. They produce
more than 40 known diseases, among
them polio, the common cold, measles
and mumps. The major problems in this
field include finding the means of
transmission, adequate methods of
diagnosing and ways of controlling the
diseases.
A recently developed problem is the
appearance of bacteria which resist the
action of antibiotics. While antibiotics
have been "dramatically effective"
against such bacteria-caused diseases
as tuberculosis and scarlet fever, their
effectiveness is being lessened by the
appearance of the resistant bacteria.
Ways of controlling these bacteria must
be found.
Some of Dr. Bauer's comments in the
Journal on individual diseases follow:
Poliomyelitis—This complex disease
will continue to be an enigma until the
basic factors governing its occurrence
and spread are found. More efficient
laboratory diagnostic tests are needed.
Viral hepatitis—The viral nature of
this increasingly prevalent disease of
the liver was found only recently. No
control measures have been developed.
Insect-carried encephalitis—Man ap-parently
only accidentally acquires vir-uses
as they go through a complicated
life cycle among other animals. In ad-dition
to the native encephalitis types,
others exist in various parts of the
world. It is not known what natural
forces may introduce these foreign vir-uses
among American insects and ani-mals
or what factors lead to their in-fection
of man.
Psittacosis— Control of this pneu-monia-
like disease, which is spread by
parakeets and some domestic fowl, re-quires
cooperation of owners, producers
and distributors in treating or destroy-ing
diseased birds. No immunizing
agents are yet available for either man
or birds.
Rabies—The virus recently was found
in insect-eating bats, which suggests
that more animals carry the disease
than formerly was thought. The dis-covery
points to the necessity of deter-mining
all animal species that can
transmit the disease to man and do-mestic
animals.
Smallpox—The last outbreak of 11
confirmed cases in New York in 1947
showed that "universal vaccination may
be an accepted principle, but ... is
not universal practice."
ni
FEB 16 1003
DIViSiON OF
y^—~^^\ TKis Bulletin will be seni ifee^ dnij cilizen of tt\e Sktj-e upon request I
Published monthly at the ofBot of the Secretary of the Board, Raleigh, N. C.
Entered as second-class matter at PystofBce at Raleigh, N. C. under Act of August 24, 1912
Vol. 71 APRIL, 1956 No. 4
Av'-^ccow v44fcS:^v
COLUMBUS COUNTY HEALTH CENTER, WHITEVILLE, NORTH CAROLINA
MEMBERS OF THE NORTH CAROLINA STATE BOARD OF HEALTH
G. G. Dixon, M.D., President Ayden
Ben J. LawTence, M.D., Vice-President Raleigh
John R. Bender, M.D Winston-Salem
A. C. Current, D.D.S Gastonia
H. C. Lutz, Ph.G Hickory
Geo. Curtis Crump, M.D Asheville
Mrs. J. E. Latta Hillsboro, Rt. 1
John P. Henderson, Jr., M.D Sneads Ferry
Lenox D. Baker, M.D. Durham
EXECUTIVE STAFF
J. W. R. Norton, M.D., M.P.H., State Health Officer
John H. Hamilton, M.D., Assistant State Health Officer, Director
State Laboratory of Hygiene, and Editor, Health Bulletin
C. C. Applewhite, M.D., Director Local Health Division
Ernest A. Branch, DJ).S., Director of Oral Hygiene Division
A. H. Elliott, M.D., Director Personal Health Division
J. M. Jarreit, B.S., Director Sanitary Engineering Division
Fred T. Foard, Director Epidemiology Division
List of free health literature will be supplied by local Health Departments or on
written request.
CONTENTS Page
Mental Health Needs and Resources In North Carolina 2
Notes and Comment 10
MENTAL HEALTH NEEDS AND RESOURCES
IN NORTH CAROLINA^
Preliminary Report to the North Carolina Academy of Preventive
Medicine of Committee Number One for the Study of Mental Health
BY FRED G. PEGG, M.D.*
Winston-Salem, N. C.
At a meeting of the Academy of Pre- continuous; and that long range ob-ventive
Medicine at Chapel Hill, Janu- jectives should be set up, with sugges-ary
17, 1955, certain projects that might tions as to how to attain them,
enhance the prestige of the Academy Our committee was assigned "To con-and
serve to advance health were con-sidered.
Among them was the study of 'Health Officer of Forsyth County and
Tmve,QnTitfar.li ih,e^a.,l!t*!h,, a„njd it. wo commit-tAees chauman of Committee One. Other com- mittee members are: Drs. B. M. Drake and
were appointed to carry out this study ^- T. Foard, state Board of Health, Ra-
Tm^eP Pcnonncspenncsiuisc ooff +tVh.eQ AA,c>oa,d^«ervm,,yr ^w^a.s^ leigh; and Dr. J. J. Wright. University of North Carolina School Sf Public Health,
that all phases of mental health should Chapel Hill,
be considered: that the study should be ^5"o?£"^?rolinrM^JiTclTJournal
April, 1956 The Health Bulletin Page 3
sider methods useful in determining
the needs of the community in refer-ence
to services for the prevention or
alleviation of mental diseases, includ-ing
techniques and indices which might
be useful." It soon became apparent
that it would be difBcult to limit our
studies to the area specifically assign-ed.
This matter was discussed with the
chairman of the other committee,
which had been assigned to consider
a mental health program for a com-munity
which did not necessarily re-quire
a preliminary survey—for ex-ample,
what clinics might be estab-lished,
what education might be used,
what services might be rendered, and
how mental hygiene can be incorporat-ed
into public health services. It was
decided to include other phases of
mental health in our survey, and, in
order to prevent duplication, to com-bine
the reports prior to final presenta-tion
to the Academy.
General Survey of Mental
Health Problems
The first step in this study was to
make a general survey of the mental
health problems and needs of the com-munity.
It was intended to get as much
factual information as possible and, at
the same time, to determine the think-ing
and reaction of the public to mental
health generally. For example, what
community mental health problems are
considered most important, how can
these problems best be met, what addi-tional
facilities are needed, and so
forth. We discussed mental health with
members of the medical profession,
welfare departments, schools, juvenile
courts, ministers, personnel directors of
industries, social workers, psychiatrists,
and others. All persons interviewed ex-pressed
great interest and seemed
anxious to cooperate; however, the
majority saw the problem from a limit-ed
point of view rather than as an
over-all need. This attitude was to be
expected, since each person was in-terested
primarily in mental health as
it affected his work. General informa-tion
and attitudes in the survey were
easy to obtain. On the other hand,
specific and detailed data were, in most
cases, non-existent.
When we began to compile the re-sults
of our studies, we were struck by
the fact that many different people
and groups were dealing with different
phases of the problem. Since we were
trying to conduct our study from the
community point of view, we decided
that it would be worth while to classify
mental health problems as nearly as
possible as they were seen by the
people of the community who deal with
them from day to day.
Mental Health Problems as Seen by
the Community
The psychotic group
The group in which the community
seemed to be most interested was the
psychotic, which includes those indi-viduals
who have been treated and re-turned
to the commvmity, those under
treatment, and those who are psychotic
but who have not been diagnosed.
It is not too difficult to determine the
approximate number of psychotic pa-tients
in a commimity. Records of those
committed to mental institutions are
available in the office of the clerk of
the court. Certain cases being treated
in private institutions are not recorded,
but this number is relatively small. The
number of new patients who require
admission to a hospital each year is
approximately 75 per 100,000 population.
Most of these require treatment for a
year or more, some for much longer,
and many for life. Thus the care of the
psychotic patient becomes tremendously
important. No other single medical
problem is of such concern to the com-munity.
While the incidence of tuber-culosis
is close to that of psychosis,
the shorter hospital stay and the higher
recovery rate of tuberculosis patients
make this disease second in importance.
Let us look for a moment at the
problem the psychotic creates in the
community. Considerable stigma is
attached to mental disease, and people
are still reluctant to acknowledge that
a member of their family is insane.
They tend to delay treatment imtil it
becomes absolutely necessary, and even
then try to keep it as secret as possi-ble.
Page 4 The Health Bulletin April, 1956
Pui-thermore, the average individual
is poorly informed as tx> the early
symptoms of insanity. Yet the p>atient
rarely has any insight into his con-dition
and must depend on his relatives
and friends to make or suspect the
diagnosis and get him under treatment.
Consequently, the diagnosis is frequent-ly
delayed until the disease has ad-vanced
beyond the early stages and the
patient has become immanageable.
Only then does the family reluctantly
accept his condition and recognize their
need of advice. Usually they consult
the family doctor, who all too often is
not able to give much help. The aver-age
physician is not well acquainted
with the various types of mental illness
and has little interest in such patients.
As a rule general hospitals will not
accept psychotic patients for treat-ment,
and it is often diflficult to make
a proper diagnosis in the home. As a
result, many patients have to be con-fined
in local jails, which, of course,
lack adequate diagnostic and treatment
facilities. Treatment is thus further de-layed
and the chances of arresting or
curing the diseases are greatly dimin-ished.
Not only is diagnosis delayed, but
often facilities in state hospitals are not
readily available, and it is necessary to
keep the patient confined in jail for a
period of several days or even weeks.
This situation usually serves to aggra-vate
his mental disorder.
Most psychotic patients are treated
in our state psychiatric institutions,
and a good percentage are eventually
returned to the community from which
they came. Unfortunately, little or no
follow-up facilities exist. Almost no
social work is done, and the patient re-turns
to the same home and com-munity
problems that helped to bring
about his break-down in the first place.
Frequently the family has not been told
how to help him re-adjust to home and
community life, and there are few
clinics where he can continue to re-ceive
psychiatric help and guidance.
For this reason, a relatively large num-ber
of patients suffer unnecessary re-lapses
and have to be re-admitted to
the hospital.
Emotionally disturbed children
Community interest was most high in
regard to children with emotional or
personality disturbances so severe as to
interfere serioiisly with their adjust-ment
to school and family life.
Unfortunately, it is almost impossible
to evaluate this problem statistically.
It is certainly widespread. One pedia-trician,
on being asked what percentage
of his practice consisted of emotional
problems, replied that at one time or
another every child needs guidance or
help with this type of problem; how-ever,
only about 5 per cent of his pa-tients
came to his office primarily be-cause
of emotional disturbance.
In a typical community the juvenile
court handled 550 cases per 100,000
population; however, in only 135 cases
was the child involved considered to be
definitely delinquent. Despite the in-terest
of parents, schools, child guidance
clinics, and so forth, exact figures are
not available. We were interested in
finding out what the community con-sidered
were the causes of delinquency
and emotional problems in children.
The majority seemed to blame the fail-ure
of the family and the community
toward the child. It was frequently
pointed out that physical and mental
handicaps were also a big factor. Most
communities appear to be much better
able to handle the problem child than
they are the psychotic patient.
An unfortunate misconception in re-gard
to child guidance clinics seems to
exist in many communities. Unin-tentionally,
the pubUc has been led to
expect more from such clinics than
they can possibly offer. In fact, many
people seem to think that the estab-lishment
of a clinic will solve all their
mental health problems. They have
worked to establish clinics with this
idea in mind, only to find that the
cUnics were unable to care for any-thing
like the number of children need-ing
help. This, of course, is no fault of
the clinic; but the public should be in-formed
as to what a given clinic can
do, and should not be led to expect
miracles.
In setting up a child guidance clinic
April, 1956 The Health Bulletin Page 5
in an area, it would appear wise to let
the public know beforehand that a
clinic designed to meet the needs of
50,000 or 75,000 people cannot be expect-ed
to serve a quarter of a million
population. This is what has happened
in several areas in North Carolina.
Psychoneurotic adults
Adults with psychosomatic and psy-choneurotic
symptoms severe enough to
incapacitate them partially or com-pletely
were of little interest to the
community generally; however, these
persons were of considerable concern to
their families and to physicians. Such
illnesses should probably be regarded
as having both physical and emotional
aspects. It is impossible to determine
the number of individuals who fall into
this classification. Many general prac-titioners
say that from 30 to 50 per
cent of their patients have illnesses of
this type. Some clinics report that from
60 to 70 per cent of their patients come
primarily because of psychosomatic
symptoms. Actually the figure is prob-ably
much lower than indicated be-cause
patients of this type tend to
drift from one doctor to another and
remain almost constantly under medi-cal
care. Most doctors easily recognize
these patients, but few are inclined to
give the necessary time for handling
such cases properly. The number re-ferred
to psychiatrists is relativaly low
because of the scarcity of psychiatric
help and the high cost of treatment.
Mentally retarded children
The number of mentally deficient, or
retarded, children depends entirely on
the method of the classification used,
and may vary from 2 or 3 per cent to
10 per cent of the total chUd popula-tion.
The number of severely retarded
children is relatively low, and the
diagnosis is easily made. At present
little can be done for these children,
and they become candidates for in-stitutional
care.
The larger group of less retarded
children, probably approaching 8 to 10
per cent of the population, presents a
greater problem. They are unable to do
normal school work or enter any of the
skilled trades or professions, and are
therefore more likely to become delin-quent
or emotionally disturbed. Medical
treatment up to now has little to offer;
however, if mental retardation could be
recognized early and special education-al
and vocational provision made, the
community's problem would be consid-erably
lessened and many potential de-linquents
and petty criminals might be
made into useful citizens. Early recog-nition
and the provision of special
therapeutic and educational facilities
seem to offer the only answer at pres-ent.
Most communities seem to under-stand
the problem of mental retarda-tion
and are trying to do something
about it. However, the high cost and
lack of trained personnel in our school
system make progress slow.
Special problems
Psychopathic and constitutionally
inadequate personalities, chronic alco-holics,
mentally deficient adults, and
deteriorated cases create widespread
and distressing social problems. The
drur&ards, the ne'er-do-wells, the petty
criminals are encountered in every
community. They clog the courts and
sweU the relief rolls of the welfare de-partments.
They are everybody's con-cern,
but the public attitude is still
largely one of contempt and hopeless-ness.
In recent years Alcoholics Anony-mous
has done some excellent work in
rehabilitating the chronic alcoholic.
Clinics are now being started in some
areas to which alcoholic individuals can
come for medical, psychiatric, and
social service. The results have been
promising, and the public attitude to-ward
the alcoholic is changing.
The psychopathic, mentally retarded,
deteriorated cases are less hopeful. Psy-chiatric,
psychologic, and social studies
of these individuals, with records avail-able
to courts, welfare, and social ser-vice,
would be of help. Mental and
vocational evaluation could then be
made and possibly some type of super-vision
devised to keep many of them at
work and out of mischief. Supervised
Page 6 The Health Bulletin April, 1956
workshops where they could be kept in-definitely
might be set up. No one seems
to have a ready or easy answer.
Resources and Needs
The second part of our survey was
aimed at determining the resources and
needs for a community mental health
program. Since these vary considerably,
it was obvious that no one cormnunity
could be used as a basis for a study of
this type.
When this study was completed, we
realized that our findings were quite
similar to those obtained by the De-partment
of Mental Hygiene of New
York State and published in 1954. We
are therefore quoting extensively from
the New York report, "New Program
for Community Mental Health Ser-vices,"
noting where our findings vary.
We believe that the similarities be-tween
the two studies indicate that
mental health programs and problems
throughout the country are very much
alike.
. . . Nowhere in the State (New
York) were there adequate services at
the community level . . .
Services were uneverxly distributed
throughout the State. Except for a
few localities, mental hygiene cUnics
were the only mental health service
and the range was from one team for
30,000 people to one team for 353,000.
(Corresponding figures in North Car-olina
range from 400,000 to 700,000.)
At the local level, there exists no
single governmental agency charged
with responsibility for community
mental health. Significant parts of a
total mental health program are pro-vided
in many communities by educa-tion
authorities, by welfare officials,
by public health departments and by
courts, but nowhere is there a central
planning body for mental health ser-vices.
The result is overlapping,
duplication, and gaps in service, and
overextension of their programs by
some agencies.
Fragmentation of services at the
local level was aided by the fact that
financial support, although limited,
was available from a number of state
departments and agencies . . .
The mental hygiene clinic is the
community service which is in great-est
demand at the present time. This
is a relatively high per capita cost
service requiring psychiatrists, psy-chologists,
and psychiatric social
workers as the nucleus for the clinic
team. This high cost coupled with the
shortage of trained personnel makes
it necessary to plan services for fairly
large population groups.
In 1948, the former Federal Security
Agency recommended a ratio of one
psychiatric clinic per 100,000 popula-tion.
However, recent experience in
the operation of community mental
health clinics indicates that a more
realistic estimate of need may be one
full-time chnic for each 50,000
people . .
Any permanent program must take
into account the fact that, up to the
present, mental health services have
been developed by a variety of public
agencies and by a large number of
voluntary organizations. The present
inadequate level should not be wor-sened
by setting up a system which
would compel the giving up of any
existing qualified service. Moreover,
comprehensive programming for com-munity
mental health requires the
combined efforts of health, education,
welfare, judicial, and correctional
agencies, both public and private. It
is equally true, however, that there
is an urgent need for coordination
and integration by a single, responsi-ble
agency of local government . . .
There are five categories of com-munity
health services.
The first category is the one which
includes the greatest volume of ser-vices
outside the hospital. These are
involved with the process of making
an early diagnosis and providing early
treatment for individual cases of
mental disorder. In this category may
be included all of the mental hygiene
and child guidance clinics, in-patient
psychiatric services in general hos-pitals,
and the case finding efforts of
school systems, welfare agencies and
public health departments.
April, 1956 The Health Bulletin Page 7
The second category of service in
the community is that of rehabilitat-ing
the discharged or convalescent
patient from the mental hospital. The
after care clinic system has grown up
to a remarkable extent and covers
most of the communities of the state.
Although there are weaknesses in the
present intensity of rehabilitative
services to convalescent and dis-charged
patients, nevertheless an
enormous number of people are seen
every year in the after care clinics of
the state hospitals. In some com-munities
there are the begiruiings of
locaUy operated programs for re-habilitation,
particularly for discharg-ed
patients. (Our rehabilitative and
foUow-up services on both the local
and state level seem to be inferior to
those of New York State.)
A third category of community
mental health services may be label-ed
consultative. These are services
rendered by trained mental health
personnel to professional staffs of
other agencies such as welfare de-partments,
schools, courts, public
health departments and so on. They
deal with questions regarding the
mental status and the probable
abilities of an individual to fit into
the usual practices of the agencies
seeking the consultation.
A fourth category may be called
educational. Under this heading may
be included all those activities carried
out by mental health personnel to
communicate to other professionals
and to the general public what has
been learned from the clinical re-lationships
of mental health person-nel
regarding the problems of human
personality. These activities are di-rected
toward teachers, physicians,
ministers, parents, policemen, and all
other individuals who have, because
of their occupational or other rela-tionships,
special responsibilities for
the welfare and the mental health of
other persons. This field of mental
health education has only begun to
develop. There are many untapped
areas of work, areas where almost
nothing has been done systematically
up to the present time to improve the
understanding of occupations which
have a crucial relationship to the
thinking and feeling of people about
personality.
The fifth and last category of com-munity
mental health services may be
called prevention. At the present time,
it is the least voluminous of all of
the mental health activities, although
it is probably the most important. It
is true that all of the four categories
previously mentioned have been con-sidered
to be preventive or prophylac-tic.
This fifth category, however,
refers to specific efforts so to deal
with facts of community life as to
reduce the frequency with which
personality disorders occur. Two gen-eral
divisions of this category may be
described—those where the disease
has an organic cause which Is pre-ventable;
and those where we believe
the disease has a psychological cause.
With respect to the first division, pre-ventable
causes can be grouped into
travuna, infection, malnutrition and
poisoning. Examples are venereal
disease control programs, the problem
of rubella diiring early stages of preg-nancy,
the adequacy of nutrition,
during pregnancy, the problem of
minimizing compUcations of brain In-
Jiury, and the treatment of the in-fections
of childhood like measles so
as to avoid encephalitic complications
In the matter of psychological causa-tion,
there Is need, for example, to be
concerned with the maintenance of
the primary relationship a young
child has during the first years of
life. Prevention here encompasses the
implications of maternal separation,
of adoption ajid child placement prac-tices,
and of visiting regulations on
the pediatric wards of general hos-pitals.
No community can say that it has
a complete community mental health
program If tt does not take into con-sideration
all five of these activities
and If there is not one agency and a
group of people professionally pre-occupied
with the problems of seeing
to it that all five of these categories
Page 8 The Health Bulletin April, 1956
of services are provided to the people
of the community to the extent now
possible.
To these needs we have added a
sixth category which could be labeled
statistical data. Such data are needed
for several reasons. It is necessary if
the community is to understand and
appreciate its immediate problems in
mental health, as well as in setting up
a well planned program. It is also
necessary for establishing base lines for
comparison with future statistical data
to determine trends in mental health
problems. In no area in the local com-munity
did we find a serious attempt to
compile statistical data on mental
health, even though in some instances
such information and records could be
rather easily obtained. For example,
the clerk of court's office has records of
admissions to our state institutions for
the treatment of insanity. The welfare
department has records of juvenile de-linquency,
admissions to correctional
institutions, feeble-mindedness, and so
forth. It would appear that the com-pilation
of such data is essential to the
development of a good community
mental health program.
How Well Are our Present Needs
Being: Met?
In an effort to answer this question,
two simple studies were made. The
records of admissions to our state hos-pitals
for the past year were surveyed
to find out whether or not the patients
had been seen by psychiatrists and if
they had received proper diagnosis and
treatment prior to committment. It was
found that 6 per cent had been seen by
psychiatrists and could be classified as
having had adequate study and treat-ment.
Nineteen per cent had been seen
by a psychiatrist in consultation only,
and apparently to confirm the diagnosis
and sign commitment papers. Seventy-four
per cent had not been examined
by a psychiatrist at all, and apparent-ly
few, if any, of these had received
adequate study or treatment.
The second study was carried out by
sending a questionnaire to a small
group of physicians. Although the group
was small, it was designed to represent
a cross-section of the medical profes-sion.
The questions asked were: (1)
"What percentage of the patients you
see in your office do you feel could be
materially benefited by psychiatric
treatment?"; and (2) "What percentage
of the patients you feel would benefit
by psychiatric treatment are actually
referred to psychiatrists?" As was to be
expected, the number of patients classi-fied
as needing psychiatric treatment
varied considerably, depending on the
type of the physician's practice. Thus,
the general surgeon said approximately
10 per cent, while the replies of the
internists and general practitioners
ranged from 30 to 40 per cent. The
over-all average was about 25 per cent.
The percentage of patients actually re-ferred
to psychiatrists did not vary so
widely. Among white physicians the
proportion ranged from 1 to 2 per cent;
among Negro physicians, 0.1 to 0.5 per
cent.
As a third measurement, we decided
to consider the proposed mental health
clinic set-up in North Carolina on the
basis of population the clinics will have
to serve, and the estimated number
that such clinics can serve adequately.
Eight clinics must serve the entire
population of the state—approximately
4,500,000. This would mean that each
clinic must serve about 550,000 persons,
or from five to ten times the number
it could be expected to serve adequately.
It seemed safe to conclude from evi-dence
of this type that mental health
services are inadequate, and even
though the number of psychiatrists
and other workers may increase con-siderably
over a period of years, at no
time in the foreseeable future will per-sonnel
be commensurate with the needs.
Summary and Conclusions
In this survey we have tried to ap-proach
mental health from the stand-point
of the local community and have
considered three different aspects of
the problem. What are the problems of
mental health as the comjnunity sees
them? What are the mental health
needs of the local community? How well
are these needs being met?
We realize how inadequate this sur-
Ap7il, 1956 The Health Bulletin 9
vey has been. We realize that it has
not been conducted in an accepted
scientific manner and that it has not
really revealed anything that we did
not know before. We believe, however,
that it has some value and that from
it can be drawn certain conclusions
which may help to clarify our thinking
and planning in mental health.
1. Education is one of the primary
needs in mental health.
a. Although the psychoses constitute
one of the most common serious dis-eases,
the public is poorly informed
about the early signs and symptoms
and how to obtain early diagnosis and
treatment. This situation is made worse
because most mentally ill patients are
taken away from the local community
and treated in state institutions. For
this reason, the public does not ap-preciate
the extent and seriousness of
mental disease. The average hospital
does not provide diagnostic and treat-ment
facilities. As a result, general
practitioners have little interest in the
handling of mentally ill patients. These
factors have caused mentally ill pa-tients
to receive late and inadequate
treatment and care.
b. Greater stigma is attached to
mental illness than to any other disease,
with the possible exception of syphilis.
Why? There are several partial answers.
The public has been led to believe that
mental illness is something mysterious
for which there is no explanation.
People associate it with some hidden
heredity taint, some confused Freudian
concept or sex obsession, which really
means nothing to them but which
serves to attach a high degree of
stigma to the condition. Would it not
be much simpler and wiser to admit
that we do not know the cause or
causes of mental illness any more than
we fully understand the causes of
rheumatoid arthritis or atherosclerosis,
but that pathologic and physiologic
causes exist just as in other diseases?
It has not been long since the causes
of rickets, diabetes, and paresis were
unknown.
2. Our present approach to mental
health problems is unrealistic. The
statement, "too little too late," could
be applied to our thinking and plan-ning.
We cannot hope to have, in a
reasonable time, enough trained per-sonnel
or funds to do the job with our
present plan of attack. Obviously, we
must explore ways and means of
achieving a mass approach. We should
seek advice and help of other groups
particularly general practitioners, wel-fare
departments, and schools.
3. Each local community should in-vest
some responsible group or board
with the authority to plan and carry
out a mental health program. Up to
now, various agencies and various
groups have attempted, in a limited
way, to deal with the problem. Results
have not been good and imless the re-sponsibility
is assigned to one group,
future planning and coordination will
be inadequate.
4. At present relatively little atten-tion
is paid to the psychotic patient in
the local community. Such patients are
often confined in jail, where diagnostic
and treatment facilities are lacking and
where the environment tends to aggra-vate
the patient's condition. General
hospitals should provide diagnostic and
treatment facilities for mental patients.
5. Local communities have made
relatively little effort to gather or
analyze statistical data on mental
health problems. It would not be diflEl-cult
for local health departments or
other agencies to compile statistics re-garding
mental illness and other phases
of mental health. Such an effort would
serve to focus community interest on
the importance of these problems and
would be of considerable help in
evaluating trends in mental disease in
the future.
6. Finally, we feel that we know only
a few of the answers to the problem of
mental health and would suggest that
the Academy of Preventive Medicine
continue its study.
10 The Health Bulletin April, 1956
NOTES AND COMMENT
BY THE EDITOR
PEDIATRICIAN RECOMMENDS
"FENCING IN" TODDLERS
An Evanston, 111., pediatrician has
recommended that preschool children
be separated from "adult gadgets and
trouble" for at least half of their play
time.
Dr. E. Robbins Kimball said this will
help the child in his adjustment and
adaptability by allowing him to escape
the adult "no" for part of his time and
by slowing down the expansion of his
world to the point where he can handle
it.
A child does not really understand
what belongs to him and what belongs
to his parents until he is four years
old. Until then he should be relieved of
the responsibility of not touching the
possessions of adults for half of his
playing hours (four hours a day), Dr.
Kimball said in the Journal of the
American Medical Association.
Because parents cannot live in a
nursery, Dr. Kimball suggested that the
child be separated from the adult
world by means of a play pen, gated
room or porch, fenced yard, or nursery
school, depending on his age.
Such "compartmentation" gives ner-vous
mothers relief and decreases the
number of household accidents. In
addition, its prevents the child from
developing habitual patterns of resis-tance
to adults as they try to direct
him.
In a study of 363 children, followed
for five to 10 years, Dr. Kimball found
that a child adapted to new situations
more readily as soon as he escaped the
adult "no" for half of his play time. In
fact, toddlers' adaptability increased
fourfold with "fencing in."
He also found that being a first child,
having nervous parents, and not being
breast fed, had an adverse effect on
the child's adaptability.
Many first children had difficulties
in adjustment because their parents,
being unfamiliar with growth, expected
them to perform at about twice their
developmental level.
"Many of these parents would have
been indignant if a school system had
tried to force their nine-year-old child
to master a topic such as calculus. Yet,
many persisted in teaching their two-year-
old the differences between mine
and thine, not to spill food, not to
suck his thumb, to give up his bottle,
and many other habits that he was not
ready to master until twice that age,"
he said.
Dr. Kimball found that children who
had trouble adapting "looked with
questioning, frequently with appre-hension,
and too often with great fear
at all adults" during examinations.
Others, instead of being cautious, were
boldly aggressive and ignored direction.
Children who showed more adaptability
were calm and smiling and enjoyed the
examination.
PYORRHEA REQUIRES BOTH
DENTAL, MEDICAL CARE
Diagnosis and treatment of bleeding
gums must be a cooperative project of
doctor and dentist, an editorial in the
Journal of the American Medical As-sociation
said.
"Periodontal disease (pyorrhea) is by
far the major cause of tooth loss In
individuals over 35 years of age," it
said. Inflammation of the gums is pres-ent
to some degree in most persons
who eat chiefly soft and cooked foods,
and gums may bleed from a variety of
causes, local or systemic.
Local irritation of the gums is al-most
always the primary cause, al-though
occasionally some underlying
systemic factor may cause bleeding in
the absence of local irritation. Most
frequent local causes are tartar ac-cumulation,
injury, abnormalities in the
bite, food impaction, and ill-fitting
dentures or fillings.
It would be a mistake, however, to
consider all gum bleeding as a sign of
uncomplicated gingivitis (inflammation
of the gums) or periodontitis (inflam-
April, 1956 The Health Bulletin 11
mation of tissue surrounding the tooth),
as is frequently done, the editorial
said. The bleeding may be a sign of
serious general disturbance, such as
scurvy, pellagra, diabetes, leukemia,
pregnancy, allergy, or lead, bismuth, or
mercury poisoning.
The editorial said that local treat-ment
by the dentist can correct the
mouth condition if there is no under-lying
systemic disturbance. But, if there
is an underlying cause, treatment of
that condition alone will not stop the
bleeding. There must also be local
treatment by the dentist.
Prescription of vitamin supplements
as the sole treatment for bleeding gums
is "irrational and ineffectual," he said.
Antibiotics may serve to relieve the
acute inflammation, but the condition
almost invariably returns as soon as
the antibiotic levels are no longer
effective. Removal of tartar and other
local factors is necessary to achieve
lasting effects.
Physicians and dentists must fre-quently
refer patients to each other for
dental or medical surveys, since the
best results in the treatment of py-orrhea
can be obtained only when all
the causative factors, usually more than
one, are discovered and treated, it said.
EARLY TRAINING MAY PREVENT
CHILD'S SPEECH DEFECTS
Guidance of mothers in the early
management of speech behavior of their
children may help prevent speech
defects in mentally normal children,
two physicians and a nurse said recent-ly.
A study of 290 mentally-normal child-ren
with speech defects was reported
in the Journal of Diseases of Children,
published by the American Medical
Association. It was done by Dr. Ben-jamin
Pasamanick, Columbus, Ohio,
Frances K. Constantinou, R.N., Balti-more,
and Dr. Abraham M. Lilienfeld,
Buffalo, N .Y.
In earlier investigations the physi-cians
found that childbirth abnormali-ties
are significant in the background
of cerebral palsy, epilepsy, mental de-ficiency,
and some childhood behavior
disorders. They thought speech defects
might also be related to such abnor-malities,
because specific injury to the
brain in adults has been reported to
result in speech defects and because
speech disorders are very common
among children with cerebral palsy and
mental deficiency.
Records of 290 children, born in Balti-more
since 1940, with speech defects
but without mental deficiency or cere-bral
palsy showed no more complica-tions
of pregnancy and delivery, pre-maturity,
or abnormal conditions of the
newborn than did records of a similar
number of normal children without
speech defects.
However, the discovery that there
were more twins and more later-born
(third, fourth or fifth) children in the
speech defective group suggests that
psychological and social factors play a
role in causing speech defects, they
said.
It is possible that twins who have
more contact with each other than with
older children learn from each other
immature, faulty, speech patterns which
become fixed due to their closeness and
mutual comprehension of their impair-ed
speech, the authors said.
It might also be that later-born
children develop speech defects because
of rivalries, disorganizations, and frus-tration
in large-family living. The im-patience
of older family members with
speech in the younger children or the
lack of attention from a busy mother
with several children might also con-tribute
to the production of speech de-fects,
they said.
The prevention of some of these
socially and psychologically disabling
disorders may lie in the guidance of
mothers in the early management of
their children, they said, adding that
further study of these factors is neces-sary.
The study was aided by a grant from
the Foundation for Mentally Retarded
and Handicapped Children of Balti-more.
12 The Health Bulletin April, 1956
DOCTORS NOTE REDUCTION IN
OPERATIVE RISKS FOR AGED
A comparison of records for the last
decade with those of 20 years ago show
the falsity of the adage "the older the
person, the greater is the operative
risk."
Drs. Carl A. Moyer and J. Albert Key
found that for many operations the
risks now are the same for persons
over 60 years as for persons under 60.
Survival rates for all ages have in-creased
greatly in the last decade, and
especially for the older group, they said
in the Journal of the American Medical
Association.
One reason for the change is im-proved
treatment of postoperative in-fection
through the use of antibiotics.
This is particularly true for cholecys-tectomy
(removal of the gallbladder)
and appendectomy, which used to have
high death rates because of infection.
The outlook is now about as good for
old as for young patients.
Greater skill in administering anes-thetics,
fluids, and blood have also
helped to reduce risks. Anesthesia,
long considered an important factor,
actually is comparatively unimportant,
except in operations which otherwise
are of little risk, such as those for
hernia, appendicitis, and the thyroid
disorders, they said.
Their study showed that aging itself
is not "an insuperable barrier" to per-forming
needed surgery on more pa-tients
without pushing over- all risk be-yond
an acceptable level, they said.
The extent of the surgery is not as
important in determining operative risk
among the aged as is the duration of
physiological upset before, during, and
after the operation, they said. Although
it is hard to evaluate the degree to
which a patient's strength has been
undermined by a long period of pre-operative
illness, this is important in
determining the risk.
Some rather involved operations, such
as removal of a breast or cholecystec-tomy,
have low operative risks because
the following physiological upset is re-latively
brief, while some less complex
operations with long recovery periods
have significantly higher risks. The
operative risks are similar for both old
and young in thyroidectomy, hernia
operations, and partial removal of the
stomach for duodenal ulcers, they said.
Heart-lung diseases also have become
less important in determining operative
risk for the aged. In fact, except for
some very serious conditions which in-crease
the risk regardless of age, the
cardiac-pulmonary condition of the
aged patient has little effect on opera-tive
risk, they said. Conditions which
have an effect at any age are angina
pectoris, repeated myocardial infarction,
uncontrolled cardiac failure, and malig-nant
hypertension.
REASONS GIVEN FOR DELAY
IN SEEKING SURGICAL CARE
A new explanation of the familiar
experience of putting off a visit to the
doctor even when danger signals are
present was given recently by a group
of Cincinnati researchers.
One of their major findings in a
survey of Cincinnati surgical patients
was that people do not delay just be-cause
they aren't aware of what the
danger signs mean.
In fact, among 200 patients the per-son
who was totally ignorant of the
importance of danger signals was "ex-tremely
rare," indicating that the medi-cal
profession and medical publicists
have done a good job of educating the
public, they said in the Journal of the
American Medical Association.
Of the 200 patients surveyed, 23 had
no opportunity to delay seeking surgi-cal
treatment, and no information was
obtained on 11. Of the 166 patients who
had an opportunity to delay, 71 did so,
they said.
Many of these delayed, not because
of ignorance of the danger signs' mean-ing,
but because of various personality
and emotional factors, the survey show-ed.
In addition, it disproved several other
reasons frequently given as causes of
delay. Delaying patients were of all
ages—not "young and foolish" or "old
and fatalistic." There was no difference
in intelligence between those who de-
April, 1956 The Health Bulletin 13
layed and those who did not. Sex was
not a factor; men and women were
almost equally represented in both de-lay
and nondelay groups.
The survey neither confirmed nor
denied the idea that cost influences de-lay.
All of the patients were in a hos-pital
which provides care even for those
who cannot pay, but some might have
delayed because they were ashamed of
having to accept free treatment.
Their study also disproved the idea
that delay is a symptom of one or
another specific type of mental illness.
There was no significant difference in
the psychiatric diagnoses of delayers
and nondelayers.
The researchers did find, however,
that delay resulted from various con-scious
and unconscious factors operat-ing
before, during, and after recogni-tion
of a sign or symptom. The kind of
illness suffered could play a part in
the delay, but was not by itself a
sufiicient reason, they said.
While the medical profession and
publicists have been successful in reach-ing
most persons with straight informa-tion
about disease, there is still much
to be done to overcome these emotional
factors causing delay, the authors said,
suggesting that there be some changes
in the emphasis in public education
and that more attention be paid to the
emotional factors during medical and
surgical treatment.
Making the report were James L.
Titchener, M.D., Israel Zwerling, M.D.,
Ph.D., Louis Gottschalk, M.D., Maurice
Levine, M.D., William Culbertson, M.D.,
Senta Cohen, Ph.D., and Hyman Silver,
Ph.D., from the departments of surgery
and psychiatry. University of Cincinnati
College of Medicine. Dr. Zwerling is
now at Albert Einstein College of Medi-cine,
New York. The study was sup-ported
by a grant from the National
Institutes of Health, Bethesda, Md.
HARDENING OF ARTERIES
POUND IN ELEPHANT
Heart attacks resulting from the
effects of hardening of the arteries can
strike elephants as well as men and
dogs, three California doctors said.
They reported an autopsy on a fe-male
Indian elephant who died of acute
heart failure secondary to severe
arteriosclerosis in many small arteries
aroimd the heart.
According to the physicians, their re-port
in Archives of Pathology, publish-ed
by the American Medical Associa-tion,
is the first one describing arterio-sclerosis
in elephants. It has previously
been found in humans, cats, dogs, pigs,
birds, chickens, and cows.
Few autopsy reports on elephants
have been made, but studies go back
to ancient Greece and Rome, the
authors said. Both Aristotle, the Greek
philosopher, and Galen, a Greek phy-sician
who lived in Rome about 200
A.D., reported elephant studies, with
Galen describing a heart condition as
"a bone in the heart."
The San Francisco elephant was at
least 47 years old and had lived in the
San Francisco Zoological Gardens since
1925. The animal, which appeared
healthy the night before death, was
found lying on its side and unable to
rise a few hours before death.
Autopsy showed severe arteriosclerosis
of the major arteries. In the small
coronary arteries, the disease was
similar to that observed in birds, dogs,
cats, and humans. However, deposits
of fatty substances, usually found In
the small arterial walls of humans
with similar disease, were absent.
Similar narrowing of the arteries with-out
fat deposits may occur in old dogs
and cause sudden death, they said.
The physicians said that heart fail-ure
occurred in the elephant apparent-ly
because the narrowing of the small
coronary arteries diminished the blood
flow to the heart. The same thing has
happened in human beings. Not only
are the physiological occurrences
similar in man and the elephant, but
the same terms—"acute myocardial
failure" due to "coronary insufBciency"
—are used in autopsy reports to describe
the conditions.
Drs. Stuart Lindsay, San Francisco,
Richard Skahen, Oakland, and I. L.
Chaikoff, Berkeley, from the depart-ments
of pathology and physiology of
14 The Health Bulletin Apnl, 1956
the University of California School of
Medicine, did the work under grants
from the Alameda County Heart As-sociation
and the United States Public
Health Service.
SOAP, FACE TISSUES MAY
CAUSE DERMATITIS
It apparently isn't possible to put out
a product for use on the skin that
won't cause somebody, somewhere, to
break out in a rash, according to two
reports.
A new product might be used safely
by two million people but not by the
one w^ho is sensitive to something in it.
Doctors treating hard-to-explain skin
troubles often have a hard time find-ing
a solution unless they can discover
the individual's particular sensitivity.
The list of possible causes of sensitivity
is long.
Two more items—an antiseptic soap
and facial tissues—were added to the
list by reports in the Journal of the
American Medical Association.
The report by Irvin H. Blank, Ph.D.,
of the Harvard Medical School derma-tological
research laboratories, Boston,
said that ordinary soap generally won't
bother anybody. But excessive use
might be partly responsible for skin
trouble or aggravate a preexisting skin
condition among a few people. And
some rare individuals have been found
to be sensitive to dyes or perfumes in
otherwise harmless soap. Dr. Blank
said he has now found this is also true
of a soap containing a chemical intend-ed
to make it antiseptic.
In the other report, Drs. Samuel M.
Peck and Laurence L. Palitz, New York,
said so-called "wet strength" facial
tissues, which have been treated to
make them more moisture resistant,
might bother some people.
Dr. Blank said the presence of a
chemical (tetramethylthiuram disulfide)
in an antiseptic soap causes rashes
among persons already sensitive to the
chemical from contact with rubber
products containing it. However, few
other persons appear to be sensitive to
the chemical in the soap. In a 17-
month period only about one case of
dermatitis for every two million bars of
soap sold was reported to the manu-facturer,
who has kept close watch on
the situation. Dr. Blank concluded that
there appears to be no more allergic
reactions to the soap among ordinary
users than there were before the addi-tion
of the chemical.
The New